I am 18 years old and going to a midwife for my first exam. I have never had an internal exam and am wondering what to expect. How is a pap smear done and is it painful?

Women should begin annual gynecological exams at about 18 years of age or earlier if they become sexually active and find themselves in need of birth control. Of course, a visit should also be scheduled earlier if any problems are encountered with the menstrual cycle or if pain or abnormal discharge occurs.

A typical gynecological exam should include a full physical or at the very least should involve an assessment of the thyroid, breasts, heart, lungs, abdomen and pelvis.

A thorough history is taken prior to the exam and the woman should be instructed in how the exam will be conducted, the collection of specimens, the sensations she may experience and what follow up might be necessary.

Before the exam begins, ask for a mirror so that you can see what is going on and you can learn more about your anatomy.

A metal or plastic speculum is placed into the vagina in order to do the pap smear. They come in several sizes so ask if your provider can use a small one, especially if you have never had intercourse. They should be kept warm in the drawer or the blades can be run under warm water for your comfort.

The pap is a screening test performed for the detection of cervical cancer. The procedure varies somewhat depending on the site, but in general it is collected with two separate devices. One is a thin soft bristled brush which just fits into the cervical opening. It is gently turned and cells are collected and placed onto a glass microscope slide. The second device is usually a wooden spatula that is shaped to match the external contour of the cervix. This is passed gently around the outside of the cervix and again cells are placed onto the slide. This specimen is then sealed with a fixative or spray and sent to the cytology lab. Results are typically back within one to two weeks.

Some women have no sensation during the pap smear and others experience it as a "pinching" or "tugging" feeling deep inside the vagina. Very few women have pain during the collection. Occasionally, the cervix will bleed for a few minutes after the pap, so a provider should explain this to the client and provide protection for her.

Cultures may also be taken at this time. If a woman has symptoms of irritation, burning, itching or abnormal discharge, a sample of any secretions are taken and viewed under a microscope. Frequently, a diagnosis can be made in a few minutes and treatment and preventive strategies can be discussed. Women do not generally experience any discomfort during the specimen collections. A cotton swab is used for cultures which may be done for chlamydia, gonorrhea, or beta strep. A herpes culture, when collected from the actual lesion, is the only culture which may actually be "painful."

The second part of the gynecological assessment is the bimanual or "pelvic" exam. This is done to feel the size, shape and consistency of the uterus, and tubes (if palpable) and the ovaries. Two fingers are introduced into the vagina and a hand is placed on the woman's lower abdomen. With both hands working in unison, the structures and any deviations from normal can usually be felt. Relaxing the abdomen and having an empty bladder make the exam easier to perform and much less uncomfortable. A recto-vaginal exam may be done at the end. The entire exam (which may take only five to ten minutes) may cause discomfort but it should not be painful.

Make sure you explain to the nurse that this is your first exam so a special effort can be made to put you at ease and to explain the equipment and the sensations you will experience.

Fear of this exam has resulted in significant morbidity and even mortality, as well as pregnancy. You might want to consider making your initial visit with a nurse midwife or nurse practitioner. This exam provides an important opportunity to discuss normal physiology and anatomy, to share concerns and do some preventive screening.