Let’s liberate women from the speculum

Within minutes, I’m lying spread-eagled with my feet in stirrups and the clinician’s face disconcertingly close to my nether regions. As I hold my breath, the practitioner, with a smile too cheery for the situation, produces a jangly steel clamp that would not look out of place in an assortment of medieval torture devices. The bivalve thing taunts me with its clumsy tambourine clatter as its sharp edges enter my most sensitive anatomy. Once inside, a scissor-like mechanism opens me up to reveal my cervix.

The instrument, formally known as the vaginal speculum, is as technologically primitive as the era that spawned it — a maladroit, Procrustean apparatus guaranteed to unsettle even the strongest of constitutions. As I reclined on a clammy table in a clinic in Boston, home of one of the most progressive medical and biotechnology ecosystems in the world, it struck me: How, in a time of untold innovation such as we live in, is this aspect of women’s health care — the dreaded pelvic exam — still stuck in the 19th century?

Not long after, I decided first to take aim at the speculum and next, to reconsider the pelvic exam.

In the 1840s, American physician James Marion Sims developed a treatment to repair a vaginal fistula, a debilitating complication of childbirth. Sims, credited as “the father of gynecology,” was a plantation physician in Montgomery, Ala., and his process involved surgical experimentation on unanesthetized enslaved women. In order to improve visibility during his procedures, Sims fashioned a device — derived from the bent handle of a silver spoon — with two pewter blades that could hinge open to extend the vaginal walls. The much-reviled speculum was born. Nearly two centuries later, the duck-billed speculum is still the gold standard despite being practically indistinguishable from an early prototype that unquestionably neglected patient comfort and dignity.

This lack of progress is exacting a toll on women’s health. With diminished adherence to preventive care, the percentage of women overdue for cervical cancer screenings increased from 14 percent in 2005 to 23 percent in 2019. Cervical cancer is a preventable disease given routine screenings for precursors, but today, advanced-stage incidence is on the rise.

Galvanized as only an enraged young person can be, I began researching materials and sketching designs for a new and improved speculum. I examined the markets and ran cost analyses. I recruited a biomechanical engineer to help me.

With great enthusiasm, I applied to MIT’s Sandbox Innovation Fund and received a $5,000 award to dedicate to understanding consumer needs. Operating under the project name Anarca, a tribute to one of the enslaved women ensnared in Sims’s experiments, I collected hundreds of data points from patients and providers to inform product features. Over the course of six months, I went to gynecologists five times just to get face time with overbooked practitioners. With my legs open wide, I would complain about the speculum and ask them for their business card. In every subsequent clinician interview, I heard some version of the same thing: “My patients hate it. We need a better solution.”

Validated by provider support, I turned to the patients. I ran a survey in late 2022 and discovered specific sources of distress during speculum insertion. Among 326 respondents, the most common causes of discomfort were intravaginal pressure (67 percent), cold temperature (63 percent), the invasive nature of the exam (56 percent), tool sharpness (40 percent), feeling uncomfortable being naked below the waist (29 percent), clanky metal noises (21 percent), and improper sizing of the speculum (11 percent). Seven percent of respondents reported that speculum insertion evoked memories of past trauma.

As a rule, routine medical exams should not instill dread in patients, so a popular approach would have to address both physical and psychosomatic pain points. While some new designs have emerged for more ergonomic specula — from ones with four bills to ones that have cameras to ones that inflate — none has achieved the mass adoption required to eradicate convention.

Recognizing the speculum’s cockroach-like capacity to survive technological evolution, it dawned on me: The innovation that will disrupt the status quo is not a new device for an already invasive procedure — it’s one that will reduce the need for the procedure altogether.

In other words, it’s not time to build a better speculum. It’s time to build a better pelvic exam.

With recent advances in AI and a growing interest in technology-enabled, consumer-centric women’s health products and services — or “FemTech,” to industry operators — I believe that a speculum-free future is finally in sight. Let this be the advent of at-home routine screening.

There is a precedent for this in the FemTech space. Everlywell and myLAB Box offer at-home testing for human papilloma virus (HPV). And while their offerings leave a lot to be desired — there are accuracy and scope limitations and self-collection challenges, and there’s an additional obstacle in the requirement to ship your sample back to the lab — they corroborate my conviction that opportunity exists to eliminate in-person exams.

A successful reimagining of the pelvic exam must overcome not only mechanical and anatomical roadblocks but social and economic ones, too. The speculum is inexpensive, rarely needs replacing, and is easy for practitioners to use. As long as patients show up, it delivers what many consider to be an acceptable standard of care. In order to wholly upend the experience, then, a slew of stakeholders must be considered. A new approach must be appealing to patients, providers, and payers (read: insurance) alike.

In March, I pitched an at-home intravaginal screening device to a panel of investors at the MIT Media Lab. The design employs a soft, tampon-like insert with electrochemical sensors to capture biomarkers predictive of HPV and cervical cancer, harnessing machine learning to recognize cancer precursors. The device would inform an at-home user whether their screening was normal or whether they should see a clinician. Crucially, the model is designed with comfort in mind.

As a first application, the system would replace speculum-based Pap smears, but the rapid advance of AI extends a greater promise. I foresee eventual solutions able to test for fertility and sexually transmitted infections, perform a pelvic floor assessment, and carry out other reproductive health screening, rendering in-person pelvic exams obsolete and empowering women to take control of their own health.

The inevitability of at-home, AI-disrupted gynecological care hinges on a commitment to challenge a legacy incumbent. The emergent FemTech industry instills hope that it’s only a matter of time before specula everywhere are melted down for scrap metal and made into car parts. But to realize this ideal, we need the boldness of women to demand better, the devotion of doctors to advocate for their patients, and the will of funders to be at the vanguard of a great leap forward in women’s health care.

Eloise Davenport is a researcher and entrepreneur in Boston. She is pursuing a PhD in cognitive psychology.