Transvaginal examination - the need for care

I recently shared a study on social media which highlighted issues and concerns about transvaginal examination.

This led to a huge discussion among midwives, women and others, about the information out there about this procedure.

I have written this blog post so that those seeking to make an informed decision about this have somewhere to go in order to get the other side of the picture.

I’m not planning to cover the ‘pros’ of transvaginal examination or when this is offered in certain areas. There is loads of information out there on these things. Much of it fails to include discussion of the downsides or risks. For instance, many information sites claim that there are no risks, other than a bit of discomfort. Recent research has clearly shown that this isn’t the case.

What is transvaginal examination?

Transvaginal ultrasound examination, for anyone who doesn’t know, is a medical procedure. It is also called transvaginal ultrasound, transvaginal examination or endovaginal ultrasound. The word “transvaginal” means through the vagina, so this is an internal examination. A transducer (or probe) is inserted into the vagina so that a doctor or technician can visualise the internal organs, like the womb, cervix ovaries or fallopian tubes. You can see a picture of a probe here, along with an explanation from a woman who has had good experiences of this procedure and describes it in a reassuring way.

Transvaginal examination is a common gynecological procedure and it’s increasingly offered to pregnant women. (I say ‘offered’ because that’s what should happen. In reality, women aren’t commonly told that they can say ‘no’. It’s not presented as an offer. More on that here.) When it’s done in pregnancy, the baby can also be seen and examined.

This procedure is relatively new, at least in pregnancy, and some people are concerned about it. There are a few reasons for their concern. Some people feel that we don’t know enough about whether this is safe. Some have concerns about whether it is useful. It’s certainly not the most comfortable thing to have done, and there are also side effects. In fact, the side effects are greater than most people realise. They are the main concern in the article that I shared, which I discuss below. But before I detail that, I want to highlight two more things.

First, this is another screening test, and all screening tests have downsides. They may lead to overuse of medical intervention. More on that here. And every time we use technology like this, we are undermining women’s own knowledge. The constant use of technology implies that our bodies aren’t capable of growing, birthing and feeding babies without a shed load of expensive machinery. And that’s just not true.

But back to the article.

Lapses in infection prevention practices

Published in the American Journal of Obstetrics and Gynecology, the article that I posted was a Society for Maternal-Fetal Medicine’s Patient Safety Guideline. It was written to highlight, “widespread lapses in the procedures used to reduce the risk of transmitting infection via medical devices.” (Hamm et al 2020). The authors note that, “Two recent surveys have found widespread and extensive lapses in infection prevention practices related to ultrasound probes and other medical devices. The incidence of such lapses has been increasing in recent years.” (Hamm et al 2020).

This is an important issue that women need to know about before deciding whether or not they want to have this kind of examination. Because:

“Transvaginal ultrasound examination has the potential to transmit vaginal infections, including human papillomavirus (HPV). Areas of particular concern are the use of probe covers with high rates of leakage, use of disinfectants that are not effective against HPV, and use of coupling gel from multiple-use containers.” (Hamm et al 2020).

Reducing risk

Yes, these risks can be reduced. Yes, that’s supposed to be happening. Yes, the main source of concern in this article was practice in the USA. But since I posted this, midwives and women from several other countries have contacted me to share their concerns that safety procedures are not being properly followed in other countries as well.

The authors do list things that can help reduce these risks:

“We review these issues and recommend four steps to reduce the risk of transmitting infection. First, during every transvaginal ultrasound exam, the probe should be covered with a sterile, single-use “viral barrier” cover or a condom. Second, sterile, single-use ultrasound gel packets should be used. Third, after every examination, the probe should be cleaned to remove any visible gel or debris. Fourth, after cleaning, the probe should undergo high-level disinfection using an agent with proven efficacy against HPV, including hydrogen peroxide, hypochlorite, or peracetic acid. Glutaraldehyde, ortho-phthalaldehyde, phenols, and isopropyl alcohol have virtually no efficacy against HPV.” (Hamm et al 2020).

The problem is that, as the surveys that the authors cite have shown, these steps are not always being taken in practice. That’s a big concern. Even if you decide to have this procedure, you might want to ask whether this guidance is being followed and ask what safety procedures are in place locally.

What midwives and birth workers think

The decisions that we make about our pregnancy and childbirth journeys can shape our experiences, health and lives, as well as those of our families. But those decisions can be complex. This book is a guide to the different perspectives and approaches that exist, and it offers tips, tools and ways of thinking which will help you make the decisions that are right for you.

I want to also mention some of the themes which came up in the conversations occurring after I posted this. A big concern from midwives and birth workers was that sonographers do not always gain explicit consent before undertaking a transvaginal examination. Several had stories of situations where consent was not explicit. Others were concerned that it is not always made clear to the woman that she can decline any procedure or tell someone to stop what they are doing. So please know this: you can ALWAYS say no, and you can ALWAYS tell the operator to STOP, even if a procedure or examination has been started. You do not have to give a reason for this.

Another concern was the effect that this kind of examination may have on the developing baby. We have very, very little research on this, and this is a big concern. It was also pointed out that the lubricant and – ironically – the products used in the hope of reducing the chance of infection may have an effect on the vaginal microbiome.

In many areas, little or no account is taken of whether a woman has a history of sexual trama or abuse, which can be triggered by such examination. Some midwives, who are concerned about how this is being used in their areas, linked this with the fact that there is so little time given to discuss consent or individualised use of technologies and interventions that have become routine.

TVU as a screening test

Several of these issues are linked with the way in which transvaginal ultrasound is used as a screening test. And another way forward – as well as implementing correct safety procedures – is described in this paragraph, which I posted along with the article.

In addition to trying to make this procedure safer, we could limit the use of this procedure. We could use it only when:

(a) it might offer genuinely useful information which could not otherwise be obtained through the use of a less invasive procedure carried out by a skilled and respectful professional who trusts women’s bodies

(b) there is a specific purpose for using it, and it’s a part of individualised and not routine care

(c) there is (and I do know this is a particularly hard one for some people to grasp) good quality evidence showing that its use in that particular context is

(i) effective, AND

(ii) the potential harms are outweighed by the potential benefits, and

(d) someone actually wants this to be used on them who hasn’t been persuaded, led, bullied or coerced into saying yes, but has made a genuinely informed decision.

All of that should go without saying. It should be standard practice. Sadly it isn’t, which is why I need to write articles like this.