Hesperian Health Guides

The speculum exam

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HealthWiki > A Book for Midwives > Chapter 20: The Pelvic Exam: how to examine a woman's vagina and womb > The speculum exam

illustration of the below: a speculum.
A medium-sized speculum will work well on most women.
(you do not need to use this screw)
A smaller speculum may work best for young women, women who have never had sexual intercourse, older women who are in menopause or who are not having regular sexual intercourse, or women who have had FGC. A larger speculum may work best for women who have had many children.

A speculum is a tool for looking inside a woman’s vagina. The speculum holds the walls of the vagina open. When it is in the right position, you will be able to see the cervix, test for infection or cancer, insert an IUD, or empty the womb.

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Practice opening and closing a speculum a few times before you use one for an exam so that you are comfortable with how it works. Some midwives let a woman look at a speculum before they give her an exam. This can help the woman understand the exam.

1. Help the woman relax by touching her leg, asking her to breathe, and by being gentle and slow. Remind her to tell you if the speculum hurts and stop the exam if you hurt her.
2. Warm the speculum with clean warm water, or by holding it in your gloved hand.
3. Ask the woman if she is ready to start. When she is ready, gently open the lips of her genitals with one hand so that you can see the opening of her vagina. Make sure to explain everything you are doing as you do it.

4. Hold the speculum with your other hand. Turn the handle to one side, and slide the closed bills into the vagina. If you are gentle, the bills will slide downwards into the vagina and should not hurt the woman. As you put the speculum in, turn it so the handle is down. Be very careful not to pull her skin or hairs. Gently push the speculum all the way in. The handle should rest against the skin between the vagina and the anus.
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Note: If the woman is on a bed or a flat table and the speculum handle will not fit facing down, you can insert it with the handle pointing up.
5. Open the bills of the speculum by gently pushing the thumb-rest with your thumb. When you see the cervix between the bills, tighten the screw on the thumb-rest to keep the speculum open.

If you open the speculum but you do not see the cervix, close the speculum and remove it partway. Then try again, repeating step 4. The cervix may be off to one side a little. This is normal. Sometimes the cervix will come into view more clearly if the woman coughs or pushes down as if she is passing stool while the speculum is open inside her.
MW Ch20 Page 378-2.png
(opening of the womb)
the cervix, shown  to be about 2-and-a-half centimeters long and 2 centimeters wide.
The cervix is usually
about this big

6. Look at the cervix — it should be smooth and pink, or, if the woman is pregnant, a little blue.

Small, smooth bumps on the cervix are usually normal, but sores or warts are signs of infection.

Notice if there is discharge or blood coming out of the cervix. Thin, white, or clear discharge is usually normal and healthy. Green, yellow, gray, lumpy, or foul-smelling discharge can be a sign of infection.
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7. If the woman wants to look at her own cervix, you can hold a mirror and a light to help her see. This is a chance for a woman to learn more about her body.
8. Test the cervix for signs of cancer by using either the vinegar or Pap test.
9. To remove the speculum, pull it toward you a little until the bills are away from the cervix. Loosen the screw on the thumb-rest and gently let the bills close while pulling the speculum down and out of the vagina. The bills should be closed all the way as you finish pulling it out.
10. Give the woman a clean cloth or tissue to wipe any discharge from her genitals.
11. Be sure to clean the speculum after you use it.
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Vinegar test for cancer or pre-cancer

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The vinegar test is a very simple way to check if the woman has abnormal cells on her cervix. Abnormal cells can be a sign of cancer or pre-cancer.

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  1. Insert a speculum and look at the cervix.
  2. Hold a sterilized piece of gauze or cloth with a sterilized pair of forceps or long tweezers. You can also use a long swab if you have one.
  3. Dip the gauze into plain white vinegar (any vinegar can work, as long as it has 4% to 5% acetic acid) and wet the cervix with the vinegar. Remove the gauze. The vinegar should not hurt the cervix but it may sting a little.
  4. Wait for 1 minute. Look at the cervix again. If there are abnormal cells, you will see white patches on the cervix.

If white patches appear on the cervix, the woman needs care right away. If the white patches are not too large, they can be frozen and removed to prevent cancer. The woman can also have other tests to find out if she has cervical cancer or pre-cancer. You can save a woman's life by helping her get tested and treated early.

HPV and cancer of the cervix

Many people are infected with a sexually transmitted virus called human papilloma virus (HPV). People get HPV when they have sex with someone who has it. Some types of HPV cause genital warts. A few types of HPV are more dangerous and can cause cancer of the cervix. Most people with HPV have no warts and no other visible signs of the virus. If a woman has one of the dangerous types of HPV for a long time, it may cause cancer of the cervix.

You can do a test to find out if a woman has the type of HPV that causes cervical cancer. The test is done the same way as the Pap test, and it may be expensive. You need to send a slide with a tissue sample to a laboratory and wait 2 to 3 weeks for the results. If the test is positive, it does not mean that the woman has cancer. She will still need a vinegar test or a Pap test to find out if she has abnormal cells on the cervix caused by HPV.

Pap test for cancer or pre-cancer
For a Pap test, you will scrape a tiny bit of tissue from the cervix and vagina, and put it on a thin piece of glass called a slide. To do a Pap test, you must have access to a laboratory. At the laboratory, trained people will look at the tissue under a microscope to know if it is healthy or not.

Before the test, gather these supplies:

spatula long swab or
glass slide fixative
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a bottle labeled "95% ethyl alcohol".
  1. Insert a speculum.
  2. MW Ch20 Page 381-5.png
  3. Place the end of the spatula that has 2 points onto the cervix and roll it in a full circle between your thumb and forefinger.

    As you roll the spatula, gently scrape a very thin layer of tissue off the cervix. This should not hurt the woman, but sometimes it is uncomfortable for her. It is normal for the cervix to bleed a little.
  4. Wipe the spatula onto one end of the slide.
  5. MW Ch20 Page 381-6.png
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  6. Place the other end of the spatula just underneath the cervix where it meets the vagina. Gently scrape sideways once.
  7. Wipe the spatula onto the middle of the slide, next to the first sample.
    MW Ch20 Page 382-1.png
  8. MW Ch20 Page 382-4.png

  9. Put the tip of the swab or cytobrush about 1 centimeter into the opening of the cervix. Gently roll it in a full circle. This can be uncomfortable for the woman, but it is not dangerous.

  10. Wipe the swab onto the end of the slide that has not been used, next to the second sample.
    MW Ch20 Page 382-3.png
  11. Put a fixative on the slide.

    There are many fixatives available, but the least expensive is medical alcohol (95% ethyl alcohol). Pour some medical alcohol into a small jar and dip the slide into the jar of alcohol as soon as you have finished wiping the swab onto the slide.
    MW Ch20 Page 383-1.png
    You must do it quickly, before the tissue dries. Let the slide sit in the medical alcohol for a few minutes, and then let the slide dry in the air. If you do not have medical alcohol, you can spray the slide with hairspray.
    MW Ch20 Page 383-2.png

    You must use a fixative on the slide or the thin layer of tissue from the cervix will smear or come off and the test will not be accurate.

  12. Take the slide to a laboratory that can examine Pap tests (not all laboratories can). Take the slide within a week after doing the test.

Note: Tell the woman that a little bleeding from the vagina is normal after a Pap test.

This page was updated:11 Sep 2019