Self-swab

Recently, I have talked many women through completing their own vaginal swabs. I offer this option for a variety of reasons. Mostly, I really like women to be able to do their own vaginal swab if that is their preference, rather than someone else (me) needing to get up in there if they would prefer not. If the symptoms speak for themselves but I want to verify that my prescribing-based-on-symptoms was on-point, the swab is an easy back-up to my management plan. I typically reserve the self-swab for symptoms and history that likely align with yeast or bacterial vaginosis, but readily offer it for other reasons as well, including STI screening and Group Beta Strep (GBS) culture. If, for whatever reason, a woman declines a vaginal exam and I can offer a test to figure out what is going on and defer the vaginal exam, I absolutely will. Why? Because sometimes the vaginal exam is not needed. Why else? For this reason, and other good info here. For every reason here asking for gentle care, less exams, or overall kindness in healthcare. Or for just about any reason, because a woman declining a vaginal exam but seeking screening can and should still receive healthcare. All brought to you by the self-swab.Generally, what am I referring to? Check out the step-by-step picture below, brought to you by the public health program of North Carolina, whose providers also get-down with this method.There are a few things the self-swab accomplishes.

• Women's direct involvement in their healthcare, in a way similar to the logging of blood pressure, weight, fetal heart tone and fundal height in Centering Pregnancy
• If it is my first visit with a woman, it allows us to develop a patient-provider relationship before a vaginal exam, which helps many women become more comfortable during those exams
• Empowerment, knowledge and recognition of one's own body

There are also a few things the self-swab does not accomplish.

• Clinical provider assessment of irritation, swelling, discharge color or odor, and evaluation of external bumps or lesions the woman may have otherwise not noticed
• Palpation of cervical or uterine tenderness, possibly an indication of a longer-standing infection
• Documentation of pertinent positives or negatives during that visit based on clinical findings

By no means am I the first person to employ this method. But a fellow midwife recently recounted a story of an MD discovering that she had "allowed" a patient to self-swab, and that MD disagreed with that midwife's plan and was vocal about it. Thus, I go to the research (of which there is very little):

• Can pregnant women obtain their own specimens for group B streptococcus? (Molnar, et al., 1997, in Family Practice) First of all,  of course they can, barring the belly getting in the way, but the research question was whether a self-swab was as effective as a clinician-completed swab. Conclusion? "Patient-collected vaginal/anorectal swabs for GBS are at least as sensitive as the current practice of physician-performed swabs." (although in this abstract it reads as though the women did a better job at picking up GBS on their self-swab than the providers did...)
• Vaginal self-swab specimen collection in a home-based survey of older women (Lindal, et al., 2009, J Gerontol Psychol Sci Soc Sci) determined the self-swab is feasible, with 91% successful at their own vaginal swabs. Way to go, ladies.
• This organization will send women a kit at home for chlamydia testing, and has pictorial instructions on the website. Clearly there is a desire for women to be able to do this on their own, and companies are meeting those needs. We as providers should be welcoming to that idea as well.

Does the beauty of the self-check method end with self-swabs for vaginitis and STI screening? Heck no! Check out the following:

• My Beautiful Cervix: Pictures of cervixes throughout the cycle, with descriptions of the woman's sexual feelings and pelvic symptoms. LOVE THIS.
• Instructions on Cervical/Vaginal Self-Exam: Great instructions, and even order your own plastic exam through this site. A midwife classmate and I went to a session on cervical self-exam at the Civil Liberties and Public Policy (CLPP) conference a few years ago - awesome! A bit tricky to get to your own cervix at times, but possible, informative and fun!
• Research into self-performed pap smears: super cool idea, tricky to get cells from the specifically needed spot and not all along the vaginal walls on your way in and out. But, especially beneficial for those with vaginas who want to be able to do their own exams from start to finish, may hate the speculum and the positioning, or for whatever reason. I would love to see something like this happen, especially for those with normal histories for whom pap smear frequency is now every three or five years instead of yearly.
• Finding ways to make pelvic exams happen only when necessary and way more comfortable for all people with vaginas: super valid points brought up in this post. However, these words also reiterate the importance of describing the tests we do, why we do them the way we do, and emphasizing that everyone has the right to refuse certain types of exams or tests. Additionally, providers need to be honest and list straight up what other options are for assessment if a client seems uncomfortable. Personally, I wish this was an option for myself, since I am aware of my anatomy, can reach it, and know what's up; but all vagina-owners could with adequate education and counseling. Word.

In school, pH paper and microscopy (using a microscope) were my favorite clinical tools to for assessment either during annual exams or problem visits. Visualizing acidity or clue cells or hyphae, or smelling the fishy effect of KOH whiff test, were vital components of lecture and clinical care during my midwifery education. These are not only components of diagnostic criteria at the time of the visit but they assure that the prescribed treatment was based on a clinical tool, in addition to the woman's described symptoms.Microscopes, you say? When was the last time you had a provider swab your vaginal fluid onto a glass slide and say, I'll be right back, I've got to check this out under a magnifying glass and then give it an extra smell? In provider-land, the microscope is an incredibly helpful in-clinic tool. An Adult/Women's Health Nurse Practitioner friend and I even went to a specific training on using the microscope to assess vaginal fluid for yeast, BV and trichomonas at this really awesome place, for free. Check it out if your education or work are based on the East Coast. Also, for those still wicked into the microscope and vaginal wet preps, a quick refresher course is available here. I also had a preceptor, and now a good friend, who obsessively smells the speculum after each exam and can diagnose many things just based on that assessment. Impressive, right? She really is. (I've also heard of midwives using smell to assess stage of labor and general dilation, though have never come across these midwives personally.) History and wisdom, people. And hippie awesomeness. Smell the patchouli oil, incense, and vaginal fluid. Goodness I love this profession. And I digress.Unfortunately, my current clinics have neither microscopes nor pH paper, and I am but a new graduate who appreciates the double-check of my assessment. I wish I had the option of those extra tools, but I do not. The NuSwab is the new/nu thing, and I am for it. With a quick insert of the cotton applicator into the vagina, moistened with vaginal fluid or discharge, the woman and I, in days, will know if the cause of her woo-woo woes is one of five issues: yeast, BV, chlamydia, gonorrohea, or trichomonas. Done and done, either by me or by her, with a simple swab.Before even getting to the self-swab as an option, there is, of course, the history-taking portion of the visit to complete. If there has been recent unprotected intercourse  or concern for infection exposure, and she is having some vaginitis (vaginal irritation) or other symptoms and would like a full STI screen, I will offer or recommend a pelvic exam along with blood testing and the NuSwab (repeat HIV and syphilis screening, possibly also for hepatitis, at 3-6 months is recommended). However, for routine STI screening, the pelvic exam is not necessarily required in my book. Sometimes, the woman has some new discharge or smell but is not experiencing terribly bothersome symptoms and would rather wait for a test result to come back before taking any further steps in terms of herbs or medication, and I'm down with that plan as well.  A few extra days of any newly symptomatic infection will cause little harm while we wait for the results. And I have found, in my over 100 visits about vaginitis over the past two months, that if a woman thinks something is up with her down-there, she will openly ask me to take a look. And I trust women. So whether it is a yes or a no to a pelvic exam, I agree.For straight up vaginitis without concern for STI exposure, classical symptoms are my go-to screening tool if I am going to treat based on symptoms. What are these classical symptoms you say?

• Bacterial vaginosis: Normal discharge or thinner and grey, fishy odor especially after sex or during menses, irritation
• Yeast: vaginal irritation or itching, thick white discharge that may look like cottage cheese, pain during sex

Classical symptoms are helpful but are often subjective based on the woman's familiarity with her own body, assessment of risk, personal symptom profile, and smelling abilities. (I am one of those people who has a hard time picking up the fishy smell on the KOH test, so I'm sympathizing with others of the same affliction.) For some women, they may report copious thin discharge with no odor, or fishy odor but thick discharge, or no symptoms other than itching and feeling swollen. I have little problem treating based on classical symptoms alone when it comes to yeast and bacterial vaginosis, or starting with a cream that will likely relieve discomfort until the results come back. All other issues, I wait on the NuSwab results.Group beta strep (GBS) is a test offered late in pregnancy. Its diagnosis, treatment, and effectiveness is wrapped up in a lot of history and assumption, thoroughly well-covered in this awesome, and I mean wicked awesome, book by Amy Romano and Henci Goer. Further discussion about GBS is worthy of another post on another day. Here, I will do no more than say that if you as a provider and women as your clients decide to do a GBS test, consider the self-swab!Women with whom I've worked who have recently done their own swabs:

• Young adolescent who thought she might have had a condom break and is having some itching
• Mother recently separated who had a night out on the town and met someone, is embarrassed to even need a visit to get checked out
• Woman who injected heroin prior to pap smear visit, is unsure of her sexual activity recently, self-swab same-day and pap deferred until she is able to consent to a vaginal exam
• First-time pregnant woman who consents to a group beta strep (GBS swab), and agrees she likes the idea of doing it herself

For the woman who came in who recently used heroin, I closed the curtain and stayed in the room, talked her through the swab process before and during. I thought this was at least appropriate to complete her screening (plus a blood draw for HIV, hepatitis, and syphilis), and encouraged her to come early in the morning before she uses next time so that I can appropriately know that she is consenting to a vaginal exam for her pap smear.For the adolescent who thought the condom might have broken, we had a long conversation about sexually transmitted disease prevention, mostly with her looking uncomfortable. She wanted the STI screen. She mentioned that sex feels "okay," but not necessarily good. We talked about consent and communication in relationships, and how to make sure she was ready before starting sex. And then I drew a vulva on a paper towel and talked about the clitoris and the erogenous zones, sexual positions, and vaginal health. She agreed that a swab for STIs would be a good idea, and I instructed her through the NuSwab before she went into the bathroom.Women, if my clients can do the self-swab, so can you. Fellow providers, if I can talk women through this process, so can you. The lab results are consistently coming back positive for ability to evaluate (whether positive for an infection or not), so anecdotally it's working for me and mine. It gives women an option to take back their power during their visit. It's a feministic approach to healthcare: believing that women speak the truth and can process counseling and recommendations to make their own decision. And gives providers and new clients an opportunity to have one visit clothed if no other symptoms mandate further exam. And I think that's pretty great. Self-swab away, y'all.