Pelvic exam guidelines have changed. Here’s what to expect.

Federal guidelines have always required your doctor to explain these exams, the risks versus the benefits, and why they’re recommending doing them. This conversation is part of the informed consent process, which previously could have been done verbally.

Now, new guidelines from the Department of Health and Human Services state that hospitals have to get written consent. The guidelines, issued April 1, were effective immediately.

They apply to any hospital that receives reimbursement from the Centers for Medicaid and Medicare Services — meaning most medical institutions. While exams under sedation are especially important, the guidelines also apply to situations in which you’re fully awake and seeing a provider in an outpatient setting, provided that location is within a hospital, a spokesperson for HHS confirmed.

Consent for sensitive exams done at physician offices outside a hospital setting can be verbal. If you’re unsure whether your provider’s location falls under the new guidelines, call their office and ask.

Mandating written informed consent for those exams done under sedation is a much-needed step in rebuilding broken trust and restoring patients’ control over their bodies and health-care decisions.

Here’s what to know about your next pelvic exam — and what to do before, during and after your appointment.

Why were the new guidelines issued?

At teaching hospitals, medical students sometimes perform pelvic exams on anesthetized patients for educational purposes. One study noted that 90 percent of medical students who completed an obstetrics and gynecology rotation performed a pelvic exam on an anesthetized patient as instructed by attending surgeons. The patient may have agreed to the medical student participating in the surgery, but it was not always clear whether the patient explicitly consented to a pelvic exam by that student.

Medical students themselves began to raise a public rallying cry to protect their patients and prevent their own moral injury — eventually helping lead to several states passing consent requirements before the recent federal guidelines.

It’s a standard that has been endorsed by medical societies for over a decade, but in practice, it was not always enforced.

What should I expect my medical team to do?

There are many scenarios in which a sensitive exam may be an important part of making a diagnosis or medical decision — such as cervical cancer screening with a Pap smear or evaluating for hemorrhoids with rectal bleeding. These exams may occur when you’re sedated if they’re done at the same time as other procedures, such as colonoscopies.

My colleagues and I have been studying rectal exams and colonoscopies among patients with post-traumatic stress disorder and how to earn and maintain trust at a time when patients feel at their most vulnerable. Like many doctors, I routinely practice trauma-informed care — that is, treating every patient I see in a manner that ensures they feel empowered and safe during our visit.

This means:

• Performing sensitive exams only when necessary
• Explaining why we recommend doing the exam and what we’ll be looking for
• Obtaining consent for all exams, including consent to allow any possible learners, such as medical students, to participate
• Having a chaperone, such as a nurse, present
• Talking the patient through every step of the exam so that there are no surprises

I’d argue that these should be practiced by any physician regardless of their training in trauma-informed care, but knowing these principles as a patient can help you ask for these extra guardrails up front.

What should I do before pelvic exams?

Ask your doctor why they’re recommending the exam. In one study of 262 patients at outpatient women’s clinics, only about half understood why a pelvic exam would be done. Medical guidelines about pelvic exams have changed significantly over the past 15 to 20 years, and a 2020 study published in JAMA Internal Medicine found that about 1.4 million young women receive potentially unnecessary pelvic exams each year. You have every right to know what the alternatives or risks of forgoing it would be.

Don’t fret about prepping. So many patients get waxed or do a quick trim down there before an exam, fearing they might get judged if not. No one is judging. Enough said.

If you have a history of trauma or any other personal or cultural reason to be wary of an exam, tell your provider. You don’t have to go into any details, but I appreciate learning what is most concerning to my patients so I can work with them to help avoid anything that they identify as triggering.

Bring in a chaperone. At many hospitals and clinics, it’s standard policy to have a medical chaperone during a sensitive exam. A medical chaperone is a trained worker, such as a medical assistant or nurse, who will be present during the exam and can provide reassurance. Depending on the context, you may also be able to have a family member or friend in the room. (This typically wouldn’t be possible in a procedural room where anesthesia is given but is feasible in many outpatient clinic settings.) Discuss these options outright.

What should I do during and after pelvic exams?

Remember, you’re in total control. If this is an exam where you’re not sedated, you can say “stop” at any time. That word will cause everyone to freeze, but to help you internalize that control, have your doctor verbally confirm they’ll stop anytime you say so before getting started.

Do a breathing exercise to help stay calm. I like to practice box breathing, which activates the parasympathetic nervous system and can reduce stress. Breathe in through your nose as you count to four, then hold your breath for four counts. Exhale through your nose for another four counts and then hold your breath for a final four counts. With each count of four, imagine drawing one line of a box until you complete a closed square.

If the exam is taking longer than you expected or you’re not sure what’s happening, say something. If it’s hard to make eye contact with or see the doctor because of how you’re positioned, engage the chaperone if needed. Everyone’s anatomy is a little different, and some exams might last longer than either party anticipated — that can be okay as long as you’re in the loop about what’s going on.

Don’t forget to take care of you. Sensitive exams tend to involve some kind of lubricant like petroleum jelly. This means you’ll need something — I’m talking wet wipes and not dry, scratchy tissues — after it’s over (and possibly also a light pad). If everyone’s heading out so you can get dressed again and it’s not been made clear how you’re going to dab yourself dry, be sure to ask, or you’ll find yourself alone in your gown rummaging hastily through the medical cabinets.

If you have concerns, talk to the patient advocacy office. Many hospitals have an office dedicated to patient advocacy or patient relations that serves as a neutral party to address and investigate any concerns about your care, in a confidential manner if you prefer.

What I want my patients to know

Before your exam, tell your provider what would make you more comfortable. Want to have a pair of cozy socks and warm sweater over your hospital gown? Sure! Want to hold your friend’s (or one of our staff member’s) hands during the exam? Definitely! Want me to get through some aspect of it as quickly as possible — or perhaps slow down so I can explain the movement you’re feeling as it happens? Absolutely! I’ve even streamed “meditative spa music” in the clinic room at the request of a patient. In my outpatient clinic, there’s rarely a request I’d say no to if it made you feel more at ease.