Monday, January 28, 2008

Morbid obesity and Pap smears

(I hope this post doesn't offend too many people...please read my comments when I replied to a reader)

I have to admit. I have a hard time emotionally with severely overweight people. I'm wish I didn't, but I do. I have to really work at not being judgmental of them. I get a sinking feeling in my stomach and frustration bubbles up into my chest when I see a patient's weight is over 250 pounds. I have to really work to put on my smile and be as kind as possible. I know that they are real people, with real problems and they can be wonderful or they can be jerks. Just like every one else. I usually end up liking them after I've had a chance to visit with them.

I try really hard to provide them with the best medical care. That means we talk about their weight. I don't skip over it so that I don't offend them. I don't ignore it. I do try to understand that they would change their life if they could. They don't want to be fat. Some of them get angry with me. They don't want to be told that their health problems are linked to their weight. Some of them appreciate the honest and open communication about something they really want help with.

She weighed over 400 pounds. I met her months ago when she was sent for an emergency room follow up. She needed a pelvic exam. She said that they had broken four speculums, including metal ones, when they tried to do a pelvic on her. I knew this poor woman was absolutely horrified to find herself in a GYN office about to undergo a pelvic exam. She was embarrassed and frightened. It was only because she was fearful for her life that she was even in my office. She hadn't had a pelvic exam in over 10 years when she was 200 pounds lighter.

There are a lot of difficulties in doing exams on women who are morbidly obese (that is the correct medical term even if it isn't a nice one). They have a lot of excess fat tissue that folds in around the speculum and obscures your view. Some have so much extra tissue inside their thighs that it is difficult to even find where to put the speculum in. All the weight of their abdomen sits directly on top of the vaginal vault and the weight alone can snap a speculum. If they are very obese, they may not be able to lay flat on their backs because the weight of their chest is too heavy to allow them to breathe. Then there is the worry that our exam tables aren't built to hold a lot of weight. Probably the biggest difficulty is the women won't come in for the exams in the first place. They are just too scared or embarrassed.

I've done a lot of pelvic exams on heavy women. I've learned a few tricks along the way. I use long metal speculums with wide blades to help hold the tissue out of the way. Some people say they cut the end off a condom and slip it over the blades of the speculum to keep the tissue from folding into your view. I've never had much luck with that trick because the condom or glove just slides up the speculum instead of staying on the end. I've had women make fists with their hands and put them under their bottom to tilt their pelvis so that I could see. And for those ladies with the big bellies, I have them grab under their bellies and pull them as far up towards their chests as possible. That pulls the weight of the belly off of the speculum blades.

I spent time with this lady calming her down and letting her know that I would be as gentle as possible and that I would try not to break any more speculums on her. I told her exactly what I was going to do and what she could do to help me. She pulled on her belly, I used the greatest care and as soon as I could get that speculum open far enough to get the specimens I needed, I did them even though I couldn't see the entire cervix. I didn't break a speculum and it only took a couple minutes. She was happy to have it over with. We talked about her weight and what things she has tried so far. We talked about surgery. We talked a little bit about her life. I told her that she really needed to come back for an annual exam and a pap smear.

I never expected to see her again. She had been in tears during my exam. But she did come back. I told her she was very brave and that I admired her for coming back even though I knew it was really hard for her. We repeated the same procedure as last time and I got the Pap smear done. (Yes, it would have been better to do the pap smear last time but she was bleeding too heavily).

I really am proud of her. I really do admire her for coming back. I am flattered that she trusted me enough to come back. That's a pretty big complement. I guess that's why I love what I do. When I can get past my own prejudices, and see into the hearts of these women I take care of, I find that they are brave, loving, amazing women.


Thea said...

Maybe speculums should be made to fit the people who need them. And maybe fat people are human enough to KNOW that you don't like them and that you automatically think less of them, and that's why many would rather go for years without medical care than subject themselves to a snotty, superior attitude and knowing that they'll be snickered at behind their backs.

Oh, and my husband has no trouble finding where to put the "speculum" in, and I'm 350 lbs. And I regularly walk 5 miles for the hell of it. Put that in your pipe and smoke it.

Midlife Midwife said...

Dear Thea:
I am so sorry that my post came across as offensive. I really meant to say that "I" have the problem...not them. I am the one with the emotional reaction. Therefore it is me that needs to change. I did not mean to come across as snickering, or being demeaning. As I stated, if I can get past my own problems, I usually find them to be wonderful women.

I really meant to point out my own faults and maybe help someone else with some of the tips that work for me. I also meant to point out this woman's bravery in coming back to see me. I admire her for that. I know it must have been terribly hard for her. I genuinely do think she is amazing.

I whole heartedly agree with you, speculums should be made to fit the woman. It drives me nuts that I don't always have the right equipment. I hate the fact that we often don't have speculums small enough for my geriatric or young teenage patients either. Those exams are painful too.

And please understand, it's not that I don't like people who are overweight. I just don't know how to help them. I get scared because I think "Oh, my gosh, what if I can't get that pap smear done? What if I hurt them? What if I offend them or say the wrong thing? What if I don't know how to handle a complication they have? What if they want a magic bullet to their weight problem and I don’t have one to offer? And just like my post did for you...what if I hurt their feelings or make them angry?"

It is wonderful that you walk so much. We do know that weight does not automatically mean healthy or not healthy. It is more important to look at lifestyle, aerobic capacity or the absence of (or good control of) things like diabetes or hypertension when we decide someone is healthy or not.

So if I haven't scared you off, how can I help overcome my own fears and how can I work to give better care to my overweight women?

Thea said...

Thanks for your comment, it's good to know that you're willing to take a more thoughtful approach. I've been a medical blog addict for a while and have seen some really truly disgusting examples of bigotry out there from blogging docs and nurses, so forgive the low expectations I started with reading this post of yours. (I don't know if I have commented before but I have read here before and generally enjoy your voice!) I mean I have seen really horrible, awful, dehumanizing stuff from writers I had grown to like and respect, stuff about how some poor soul passed away and hahaha they pity the guy who has to drag them into the coffin, or how a HUUUUUUUUUUGE pregnant woman came in in labor and they don't know how she found a man to knock her up. I mean good grief, I can't help but put myself there and wonder--when I leave the exam room, does my doctor laugh about me? Complain about my flabby crotch on her blog? If I died in the ER, would they trade "necessary" black humour about how I "ate myself to death" while my baby girl was crying in her daddy's arms? I can't help but wonder when I read those comments if the medical professionals I have to trust see me as really human.

This is a sensitive subject for me not just because of myself but because I know how much my dad has been hurt by attitudes about obesity in healthcare. He's quite large, and in all the 18 years I lived at home I only remember him going to the doctor once--to get his vasectomy. Other than that, he refused to go no matter how ill he was, because he had been hurt, mocked, and shamed too many times before. Eventually he went to the doctor after he had lost 200 lbs in a few months--it turned out he was wasting from an untreated illness and was well on the way to his grave. Fortunately he was able to get treatment then and is still with us, but it sickens me to think of the years he went without because it hurt so badly to get treated like a subhuman.

I think the biggest obstacle for healthcare professionals on this issue is a set of assumptions that's like: fat is easily lost...fat is unhealthy...unhealthy is bad...therefore fat people are being bad and don't care to do anything about it. I don't mean to oversimplify, but I think that's very much the message our society shouts so it makes sense that even healthcare workers would absorb it to some degree. Debunking any of those assumptions is the first step towards getting over the emotional bias, IMHO. I highly recommend the blog Junkfood Science, it's written by a nurse practitioner who does a very thorough job of scanning the recent headlines and journal articles for research on obesity, and the fact that it's not always anywhere as straightforward as people eat too much and don't move around enough.

It's very hard for me to hear stuff that makes my body sound grotesque and that's why I reacted so strongly to your post. I didn't really hear what you were saying, I guess, because the words that were used seemed sensationalistic, like they were meant to highlight how HUUUUUUGE these women are. I know I am large, but most of the time, I don't think of myself as grotesque. It hurts so much to know that some people do think of me that way, as asexual, gross, nasty, like a sideshow act, breaking speculums and crushing exam tables and befuddling practitioners with my wads of blubber hanging into my vagina. Know what I'm saying?

I think there must be an art to doing exams on larger women, because I've had a midwife and an OB who did pelvics on me with no special tricks or anything, no problem, and OTOH a couple GPs who acted like they were trying to do the pelvic through my nose or something. I wonder if psychological comfort has anything to do with it, anxiety levels and so forth. I don't know, but I'm a social scientist so that's where I always go first, heh.

Agatha said...

I am a student midwife at the moment & have only had experience of caring for one morbidly obese woman so far.

If i'm honest, it was really difficult. I couldn't palpate (I need more experience with obese women), her scans were inconclusive as to the position of the placenta, & she couldn't really move.

I hurt myself badly helping her move, trapping a nerve in my back. So I need to move past that - I know I do... but it'll take time.

DementedM said...

I want to suggest that if you are talking to a patient about their weight to please suggest a blood test to look for an FSH/LH imbalance that is indicative of PCOS and/or an US to assess their ovaries for the cysts that are the hallmark of PCOS. Women with PCOS often will not lose weight on low fat WW type diets because of the insulin resistance associated with PCOS. Anywhere from 10-25% of women have PCOS and few are diagnosed.

The thing that frustrates me about the medical profession and their view of obesity is the chronic assumption that everyone is fat for the same reason. That is not true and it is an overly simplified view of the problem at a huge disservice to the patient.

I was 242lbs for years. At that weight, I taught aerobics and starved myself but could not lose weight. Doctors could not get past the one-size-fits-all paradigm prevalent in medical science and told me I needed to go to Overeaters Anonymous or TOPS, when really I had PCOS. The one silver lining of infertility was at least I got a diagnosis and I learned what I needed to do to lose weight.

Not everyone is fat in the same way and why science can't seem to figure that out is really annoying and feeds all sorts of negative biases.


Thea said...

Or thyroid levels. Most recently I was concerned I might have low thyroid because I had suddenly gained tons of weight (after losing all the baby weight pretty quickly) and my skin was quite dry. I know that it's quite common to go hypo after having a baby. I asked the doctor for a blood test and she laughed at me and referred me to a nutritionist. Still waiting to find out if I need thyroid medication or not.

Thea said...

Also, if a doctor ever suggested weight loss surgery to me, I'd never go back. Any practioner who recommends a surgery with that high of a failure rate, that high of a mortality rate, that high of a complication rate to a relatively healthy young woman simply because she's ZOMGZ fat!! deserves to be put out of business, IMHO. It's pure bigotry and quackery.

Midlife Midwife said...

Agatha: ouch! Sounds like it hurts. These can be difficult exams even for the most experienced. Remember all those lessons on good body mechanics when helping patients move? :-)

Thea: "I can't help but wonder when I read those comments if the medical professionals I have to trust see me as really human."
Some of us do. That's why I try so hard to overcome my first reactions, that's why I've tried so hard to find ways to help get those difficult pap smears and make them less traumatic for my patients. And that's why I appreciate help.

Thank you Thea and DementedM. I am begining to feel like I am not such a bad midwife after all. Yes, I do suggest blood tests to my overweight women to look for PCOS. Although the new Rotterdam criteria for PCOS does not use the FSH/LH ratio.

I also do testing to look for signs of insulin resistance (there is no a true test of insulin resistance.) I use metformin to treat PCOS and insulin resistance. I spend time talking about low glycemic index foods and exercise as ways to help combat the insulin resistance.
I also do routine thyroid testing. The hard part really is that many of these women have normal thyroid and do not meet the criteria for PCOS.
I do talk to them about the emotional component of eating and offer them referrals to dieticians who specialize in obesity.
I too am not a big proponent of gastric bypass as a "quick fix" for weight issues. When I say that I talk about surgery, I present it as a last option (kind of like trying everything else before you do a hysterectomy)

I am hopefull that some of the new research looking at the grhelin and leptin hormones will help us understand obesity and come up with better ways to control it. And we as a society have to look at all the reasons why obesity has become such an American epidemic.

So do you have suggestions of where to send these women for support? How do I talk to them about their weight? What words do I say so that I don't get the kind of gut wrenching reaction that makes them think I don't see them as a worthwhile person?

AtYourCervix said...

Gastric bypass was my last option, in a long line of diets and trying to change.

I was a relatively healthy young person going into surgery, and took a LONG time to decide to proceed. Then, I took almost 10 months for the preop time/diet/exercise/losing weight before surgery/consults/work-ups, etc.

I have had very minimal complications, and am actually healthier now than I ever was!

I lost 50 lbs before surgery, and then another 95 after surgery.

Gastric bypass surgery was NOT the easy way out of obesity. It's still a daily struggle that I will face for life.

Midlife Midwife said...

At Your Cervix: Congratulations on a wonderful example of how gastric bypass can be successful and the reminder that achieving and maintaining a healthy weight is a lifetime process.

By the way dear readers, At Your Cervix has a great blog as well!

Lou said...

Interesting post. I just have a small question though. When you say you get some women to put their hands into a fist and put that under their bottoms, is that only for obese women? According to most of my friends (of all different sizes) that's common practice for all women. Just wondering?

DementedM said...

MM:I don't think you can direct people anywhere--we don't know enough about obesity imo to really be able to endorse one solution over another. Actually, instead of emphasizing weight loss, I'd rather see an emphasis on health, i.e. fish oil supplements and exercise for _all_ patients no matter their size. Too many thin people get a free pass because their weight is within range and yet they aren't eating the right things or exercising either.

I may be fat (currently nursing and fobidden to do hardcore low carb) but my blood pressure is 116/70. I'm not exactly the stereotypical fat chick about to keel over like a beach whale, you know? I take my fish oil. I exercise as I can between caring for a baby and the sleep deprivation. With PCOS I'm fat because I eat fruit now, not Doritos so I really can't win.

Good health will take me further than weight imo and you can be healthy without being perfectly thin.


Midlife Midwife said...

Lou: Actually, I use the hands under the bottom trick for anyone whose uterus tips a certain direction. Gravity helps pull the uterus back into alignment so you can see the cervix. It also works for moving weight off the speculum. So yes, it is used for a lot of women.

DementedM: Thanks for the input. I do try to emphasize health. Most of us if we were doing healthy lifestyles would lose weight (or gain if too skinny. You have pointed out THE most difficult part of medical care...convincing patients to make healthy lifestyle changes.

Elizabeth said...

I too initially had a violent visceral reaction to your blog entry. I only recently saw a midwife for the first annual exam (breast, pap, pelvic, blood work) in 5 years. I've always struggled with being overweight and with stress eating and with not enough exercise. I was terrified to actually go. I cancelled the first appointment when a meeting came up (I could have rescheduled, but I was so relieved, I called the midwife instead). When it finally came, I got very stressed out (heavy traffic didn't help, nor did the poor directions Mapquest provided). At one point, I was on the phone with my husband, half sobbing, half hyperventilating and desperate to cancel. He talked me out of it.

To be fair - it wasn't just the exam (though that worried me a lot - I knew waiting so many years was irresponsible, and I feared how that would reflect on me). This was the midwife I really wanted to see during pregnancy and the midwife I hoped would attend a homebirth. I am planning to ttc this summer, and wanted to establish a relationship with someone before then. This woman came highly recommended by friends and strangers alike, and of all the people I'd met or website I reviewed, she spoke to me. I wanted her to like me. I wanted her to be willing to take me as a patient - but I already knew that she gives a strike against homebirth if your BMI is over 35 - and mine was at 49.

When I saw her, she seemed a bit surprised at my size, and there was some awkward chit-chat. We both seemed nervous. She accompanied me to the exam room and we sat down and talked. I was honest with her - that I wanted to get pregnant this summer and was very motivated to have a homebirth, and that recently, I'd begun to change my life so that I could be as healthy as possible (new job, less financial stress, eating healthy foods in good portions and working out 4-6 times a week, had lost 11 pounds already and now this exam). As we talked, we both relaxed.

She was straight-forward about my weight (I should lose some, and doing so would probably help me get pregnant more easily, my stress levels would go down with exercise, etc), but didn't dwell overly much on it.

The exam itself was fine. No problems with the speculum or excess tissue in bad places. No issues with palpating my abdomen. Once she found the extra large blood pressure cuff, she pronounced me a very healthy fat person.

Once she warmed up and treated me as a human worth interacting with, I was so much more at ease. I was honest about avoiding doctors in the past because of issues with my weight, and honest about the fact that I would not see an OB because I'd already been told I would be a scheduled c-section because of my size (which I find ridiculous). By the end, I was comfortable enough to ask the question I had most feared - would she be willing to take me as a homebirth client at my size?

And the answer was yes, provided I remained low-risk (naturally). She reassured me that she'd had larger clients have successful homebirths before and that so long as my blood pressure stayed at good ranges and my general health remained good, then I was a good candidate for homebirth.

We've spoken twice since then and each time, I've been so very pleased to hear her say, "I hope to hear from you later this year!"

What a relief - what a wonderful experience. How can you duplicate that for another large woman?

-Look them in the eye and smile. Put that woman at ease and let her know through your business-like approach that you see her and not her size.

-Don't dwell overly much on weight. It is a concern, it does need to be discussed, but as you said - we know we are fat, and there is only so much you can do.

-Have size-friendly equipment, like larger gowns (or cover ups), large blood pressure cuffs (which will give a more accurate reading), and don't make a big deal out of retrieving those items.

-Emphasize health over weight. While weight is an easy number to focus on - health is what is of primary importance. Praise good health and good habits - and remain encouraging.

-Think how you would feel if someone acted as though you repulsed them by their very presence - and how you would want them to treat you. Then act that way.

Midlife Midwife said...

Elizabeth: I am sorry about your initial reaction to my blog. Thank you so much for sharing your experience. I appreciate the tips too. I am working very hard on trying to be the best midwife I can, even if it means admitting I have have my faults. (Wow, homebirths...I am jealous. I so miss catching babies right now)

Thank you to all my readers who have responded.

Elizabeth said...

One more thing I left off yesterday - a website that has been terrific for me, that I recommend you take a look at is -- the woman who put it together has compiled some great articles on size and pregnancy, and healthcare in general.

There is even a section on how to be a size-friendly provider - it might be helpful. It was such a relief to me to find someplace that would give helpful advice about preparing for pregnancy at a larger size, and give realistic expectations about what I might be risking or encounter.

Thank *you* for working to acknowledge your weaknesses as a healthcare provider and striving to become the best caregiver you can be. EVERYONE appreciates that in their care providers.

Working Girl said...

This is such an important issue. I'm an L&D nurse and work with quite a lot of larger women. I love my job and my patients and some of the most meaningful birth experiences that I've had have been with obese women. But I do have my cranky days when I hate to see them's often a lot more challenging to take care of obese patients. It's harder to monitor the baby, harder to assist the patient in moving, often harder to start an IV or draw blood, harder to do a vag exam, harder to hold that leg while pushing. But I always try to put myself in their shoes -- imagine what they feel, because I want to always give the most compassionate care that I can. But I have been known to come home and bitch about it.

Susan Helene Gottfried said...

I dropped by thanks to working girl. I love your post; you've taught me a lot about medical care and this comment thread has taught me much. Since I'm a writer, this is a VERY good thing; I hope I can use some of what has been mentioned here to write overweight characters with accuracy and to portray them as people first.

Thanks to everyone who spoke up. You've all taught me things that my imagination never could.

FatSingleMom said...

I'm late to the discussion, but I second Elizabeth's reccomendation of the plus s-zed pregnancy website! There are also a couple of yahoo groups that you can refer pateints too for support is for women more than 50 pounds overweight and pregnant and is for those of us breastfeeding or thinking about it. There's also a yahoo group called OASIS for those dealing with infertility, but my baby was a SUPRISE so I never belonged to it.

As far a how to deal with me-- just be kind and direct. Don't pretend I'm not morbidly obese, it's not like you can miss it and if you don't mention something that so obviously effects my health and care I'll wonder what else you're not mentioning. Show me that you understand that while losing weight might be simple it's not easy. The best opening is usually something like "How do you feel about your weight right now?" The worst is "Have you ever thought about losing weight?" I slapped my palm to my forehead and said in my most airheaded voice "No, it never crossed my mind!" To be fair though, that was a student, and the doctor (who I adored) about wet his pants laughing at this exchange....

FatSingleMom said...

Oh, and when I tell you my blood pressure is 130ish over 85ish do NOT pump the cuff up to 200+ it bruises my arm every time!

Midlife Midwife said...

FatSingleMom: Thanks for commenting. I have a question for you. Wouldn't asking someone "How do you feel about your weight" be just as simpleminded as asking "have you ever thought about a diet?" I can just see my ladies rolling their eyes and saying sarcastically "Oh, I LOVE my weight and I'm actually hoping to gain more."

Would it be better to ask something more along the lines of "How do you feel about your health right now?" I'm still struggling to find the best words to say.

FatSingleMom said...

Ah, the question might be simple but the answer is complex and ever changing! I've been everywhere from suicidal to ready to join the Fat Acceptance people in their marching and protesting. Since I found out I was pregnant last June, I've decided to (mostly) ignore it and concentrate on eating lots of protein and veggies and making most of my carbs whole grain. OTOH, I'm of the firm opinion that a craving denied is a binge waiting to happen. I figure if you've been obsessing about ice cream for a day you'll be satisfied with a dish, if you've been obsessing about it for a month....

I don't know if that approach would work for everyone, but I only gained 24 pounds during my pregnancy (and I was plateud FOREVER at 17 pounds, then gained 7 the last week) I lost all the pregnancy weight immediatley-- at my incision check (we had an emergency c-section) I weighed 10 pounds less than when he was CONCIEVED! And I've lost another 5-10 since. But I think at least some of it must be the breastfeeding, I can't imagine what else would allow me to eat this much (I have NEVER been SO HUNGRY in my life!) and still lose weight. Oh, and another thing I started doing when I found out I was pregnant and have kept on with is when I'm "hungry" I ask myself if it's physical or emotional or both... Even if it's emotional I might still feed it, but it makes me more aware....


Midlife Midwife said...

Dear readers,
I don't allow advertising on my blog...or links to advertising. Especially for on-line prescriptions. So if you try to post them, I will delete them.

Tammy said...

I know this is an old post, but it is so timely to what I'm dealing with that I had to write.

I'm 45, 400+, with rheumatoid arthritis and Sjogren's Syndrome and I have asthma and take thyroid meds, but I have perfect blood pressure, my lipids and sugars are within range and, aside from the autoimmune stuff, my blood work looks as if it came from a normal sized person--except for my C-Reactive Protein, which is 8x normal.

Anyway, 2 years ago, after having crazy periods--4 months without, then 3 in one month, or 15 day periods, I broke down and made a GYN appointment. I hadn't had a Pap in 18 years. So I did the pap. It was humiliating, but I survived it, and so did the medical personnel. I was proud of myself for overcoming my anxiety and getting it done--until the test came back abnormal.

So I go back for an endometrial biopsy. The doc has a world of trouble. She actually says that something is horribly wrong with my cervix and brings a bunch of people in to take a look. A tech is holding up my stomach fat, another is holding my hand because I am crying because I am so humiliated. I am an oddity, a curiosity. A monstrosity. The procedure is finally done and I am left to dress, shaking, crying, feeling as if I have been violently attacked.

After I have dressed and calmed down, 2 of the docs come back to talk to me. My doc tells me to prepare myself for a hysterectomy, that it doesn't look good, that when she dilated my cervix, things happened that aren't supposed to happen. I was terrified.

Two weeks later--the longest 2 weeks of my life--I come back to get the report. I bring my husband with me, expecting bad news. My doc comes in, with a male colleague (this is a teaching hospital-Tx Tech) and tells me everything is fine, recheck in a year. That's it. I try to remind her about what she told me, about the abnormalities and she brushed me off as a nuisance. I left, but although I have felt I should have been happy about the results, I fear that maybe something was missed.

Now, 2 years later, I'm having more problems and really need to make that call to see a GYN, but I can't. My anxiety is overwhelming and I don't know how to get past that.

Midlife Midwife said...

Tammy, what a sad story! I am so sorry for how you were treated. It's interesting that you should write today. I had a women (morbidly obese) who came in today for her first pap in 10+ years. She was so grateful that I do my paps by myself and that no one else was in the room during the exam. She was a delightful lady.

Having worked in a teaching hospital, I know what you mean about all the spectators. I try to be really conscious of my patient's privacy.

I'm sorry you had such a bad experience. Thanks for telling your story. The more I hear of women's experiences, the more I am able to give compassionate care. I really am learning!

I do hope that you are able to find a GYN that you can trust. I like what one reader put...that she won't let someone elses bad behavior make her jeapordize her health. Being overweight causes a lot of menstrual irregularities and often we don't have great ways to treat it. But you deserve to have your problems addressed. I'm sending good vibes and hugs your way. You are stronger than you think and I know you will find the courage you need. Good luck!

Midlife Midwife said...

Tammy: you may find this post to be helpful...lots of other women have anxiety about paps as well.

Kristi said...

I wish doctors would admit their prejudices more often in a public way - that way I don't have to go to the ones that have 'problems' with me because I'm not an ideal size, or I'm not their religion, or whatever. It would probably save a lot of us time, frustration, and money.

Midlife Midwife said...

Kristi: The first step in overcoming a prejudice is to admit you have them. I did, and have to say my readers have educated me, changed my perspective and made me a better practitioner because of it. I learn something from every woman.

Well-Rounded Mama said...

I know this post is old but I just found it and would like to comment. I am a woman of size and the author of the website cited, I also now have a blog at

Midlife Midwife, thank you for your honesty about your struggles, yet trying your best to overcome your concerns and reactions. Thank you for your work trying to make things better for women of size.

So many women of size have delayed or completely ceased going to well-woman exams because of past mistreatment and humiliations (read the blog, First Do No Harm). You can make SUCH a difference by showing them that it's possible to receive gentle and understanding care. Thank you for sharing your insights on how to make a pap smear work better for very large women.

However, I do have a few gentle disagreements on other issues. For example, I don't agree that if we all emphasize healthy behavior, we'd all lose weight. It's certainly true for some people, but many fat people do not experience this at all, and it's one of our greatest frustrations that most people believe that if you only fix your habits, weight loss will always follow and your weight will "normalize". I truly think that there are some metabolic differences that have yet to be figured out that account for many differences in weight.

But that doesn't mean that such healthy behaviors aren't worth pursuing....of course they are. They should just be pursued for the sake of overall health, not just for losing weight...because by and large, significant permanent weight loss is extremely uncommon (Mann et al., American Psychologist, 2007).

You can ask your clients how they feel about their health, and if they seem defensive or opposed to weight loss treatment, then you can suggest looking into Health At Every Size (HAES), which emphasizes healthy behaviors regardless of what the scale says. Research shows that long term health gains are improved in the HAES treatment groups vs. those emphasizing weight loss. (Bacon L et al., Journal of the American Dietetic Association, 2005) It's not "giving up" or "letting yourself go"'s emphasizing the part of health that we truly can influence.

Many of us have found far greater health through a HAES approach than by surgery that often causes long-term serious nutritional deficits or by another round on the diet merry-go-round that may leave us with a net gain in the long run.

Thank you for being willing to hear others' concerns and criticisms; I know that's not easy. And thank you for being willing to acknowledge your own limitations and being willing to work through them to bring more compassionate care to women of size. I hope you will look into HAES as yet another self-care option that you can present to your plus-sized clientele.

Mandala Pi said...

hi Thea :)

I think the #1 problem here is the use of "them." it is so easy to lump any group of people together and forget they are individuals. it's semantics, but it can influence your subconscious biases. would you call another group of patients "my skinny women?" or think of each individual patient at that time?

it really helps when a medical professional handles my body firmly, not afraid to touch me or cause me discomfort. that confident touch tells me they know what they're doing. hesitance worries me.

the excess fat that laps over some women's thighs is called the "panniculum" (Latin for "apron"). the gynecologist who told me that earned my trust, normally I feel ashamed of that excess skin( from weight loss) but this was just interesting, a body part like any other. she asked me to hold my panniculum up, and using her hands confidently did a digital exam first and see what size speculum she needed. now I automatically lift my "apron" when examined, it's comfortable for me. I wish insurance would cover panniculectomy, though! it causes major back strain and pain, and movement problems.

most doctors assume large woman = large speculum and cause undue pain. I've been doing my Kegels for many years and have always needed a smaller speculum, it's just how my vagina is. the worst is when a new doctor insists they *know* I need a large speculum, rushes into it and injures me inside, then they admit they need a smaller one. it can cause pain and bleeding for days. for many years I was too shy to say anything, and suffering for it. now I always bring it up before the exam starts.

I have PCOS. it went undiagnosed for over 10 years and I gained 150+ lbs during that time. it was torture because I was stuck on "week one" of Weight Watchers, 800 calories, low carb, with miles of walking, isometrics and yoga. super healthy living, I'm a former athlete. once diagnosed, I went on metformin and lost 90 lbs. but I haven't been able to get lower than that, no matter what I do. I've become happy with myself and simply live healthy now.

I expect my PCP or a physical therapist to talk to me about my weight. I guess I don't expect a gynecologist to bring it up, except when I was pregnant. even then, I had the misfortune of a doctor assuming I would be high-risk everything, she was very pushy about early induction and elective C-section - I switched doctors! my daughter was 40 +4 and tiny. *big smiles*

unfortunately, my experience during pregnancy was in a women's group clinic, and all but one of the doctors used fat-shaming tactics on me. after birth, I had one last extremely painful exam and didn't go in for a PAP smear until my daughter was 6! I had moved and hoped to make a fresh start with a new clinic. I met the worst OB/GYN of my entire life. she started talking about my weight the instant she saw me, and would not stop. before the exam, when she asked if I had any issues, I made the mistake of asking her a question about my clitoral hood. it had became much tighter and smaller after pregnancy and I was having difficulty with orgasms and a tearing pain during sex. she just said "that's nature's way of saying you're done with sex." I expected at least a medical answer. during the exam, she insisted on using the largest speculum, I was crying and ... it just got ... worse. I felt violated. I also felt like I was being punished for my body shape. that was 3 years ago and I'm nowhere ready to dare a pelvic exam again. and sex is just too painful now.

I guess my point is, your obvious caring comes across in your writing, so if you are confident and not hesitant, women will trust you and it will help them relax. I wish I had a professional like you!

thank you for being open to hear other women's experiences, and I hope we all help each other by talking so openly about this sensitive topic.

Midlife Midwife said...

Mandala Pi: Thank you for your comments. I still continue to learn from women. One of the reasons I love what I do is that so many women truly are willing to help me learn. I am sorry you had bad experiences. And by the way, I do use the smallest speculums possible. I don't always use the largest speculums just because of a woman's weight. I often find that it is easier to get a pap smear with a smaller speculum. I am sorry if I gave the impression that all overweight women needed a large speculum. Thanks for contributing to my education.

Amanda said...

I was at the gyno today and she said she needed to do an IUD check on me. I didn't really understand why she needed a long speculum, because my vagina seems short (I use a menstrual cup and did a lot of research as to what would fit me best). Well, at 350lbs myself, I guess I know why now.

My gyno is very nice, but I always suspect that anyone I come in contact with takes one look at me and immediately thinks "Lazy pig". I've had one doctor actually say to my face that I was too fat for him to help me. My own husband isn't attractive to me anymore and honestly, cannot blame him. I see people staring and whispering in public. I get it. I don't belong in the world of humanity, because I have a weight problem. Unless you've ever have been overweight, you have no idea what it is like or how you are treated.

I have two disabilities, daily migraines and spondylolisthesis. I am in severe pain 24/7 365 days a year. Walking is usually out of the question, because I cannot stand more than 15 minutes before the pain in my back forces me to sit. If you've ever had migraines, then you know how impossible it is to exercise. I am counting calories now, and I'm only suppose to have 1600 calories a day. That's not much of a life when the only thing you can do is eat. I eat the same thing every day so I know I won't go over my calorie limit. I'm not losing weight to look prettier, but for my health.

It's a slow process, and I don't know if or when I will actually lose any weight. My weight can change up to 20lbs in a month, so me weighing 343lbs one month actually means nothing, because next month I might weigh 360lbs. I get that I don't really fit in, and that I will get the looks and laughs from people as I walk by. But I am human. I have a life and a soul. I have just as many feelings as the next person. But I understand why people have a general dislike of me. It's something I have to accept.

I apologizes profusely when my gyno has to do a pap/pelvic on me. I'm apologizing for the fact that she actually has to touch me.

Midlife Midwife said...

Dear Amanda,
I no longer blog and haven't for years. But your post was compelling enough to make me want to respond. I totally understand about how hard it is to eat when you are restricted to 1600 calories. It's hard to find enough to fill you up and yet not go over calories. You are correct that I will never be able to totally understand another person's life. That is why I am grateful that women are willing to teach me. I have learned from every person who has commented on this post. Thank you for sharing your story and helping me to see each of my patients as an individual.

Amanda said...

Midlife Midwife,

Thank you for your reply. I apologize if I came off as overly cranky; I had a trying day and it was no excuse to get snippy at you. I appreciate beyond words how warm and receptive you are and thank you from the bottom of my heart. This world needs more people like you. God bless you <3