You're Already Doing the Pelvic Exam. Here's What to Look For.
The Muscle, Tissue & Hormone Screen: Three often-overlooked parts of a pelvic exam
She's been told everything looks normal.
She's been treated for UTIs that weren't UTIs. Given antifungals for yeast that wasn't yeast. Sent to urology, gastroenterology, and psychiatry. Offered medication after medication for pain that never got examined.
And somewhere along the way, the possibility of a more thorough pelvic exam got lost.
As a nurse practitioner, I know firsthand how much of our education stops at the Pap smear. We're taught to examine the cervix and vagina, but many of us were never taught to assess the other structures that can be relevant to pelvic and sexual pain.
Entry pain. Sexual pain. Clitoral pain. Orgasm pain. Vestibular pain. Burning with urination. Pain with bowel movements.
These symptoms deserve more than a quick look and a conclusion that everything is normal.
Here's what I want every provider to know: You're already doing a pelvic exam. You just may not have been taught what else to look for.
And if you're a patient, you deserve to know that these questions can be part of the conversation, too.
The Missing Piece: The Muscle, Tissue & Hormone Screen
I teach a simple framework called the Muscle, Tissue & Hormone Screen.
It brings three often-overlooked components into the pelvic exam:
The vestibule: What does the tissue look like, and is it tender?
The clitoral hood: Does it move?
The pelvic floor muscles: What is the muscle tone?
These are not separate from the pelvic exam. They are additional areas to consider as part of it.
1. Map the Vestibule
The vestibule is the tissue at the vaginal opening. It deserves attention, particularly when someone describes pain with entry or discomfort at the opening.
Look at the skin. Is it dry? Is it pale?
When entry pain is present, a cotton swab assessment at four, six, and eight o'clock can help identify areas of tenderness.
The point is to look at the tissue and assess the area that corresponds to the patient's experience—not simply assume that a normal-looking vaginal canal tells the whole story.
2. The Hood Check
The clitoris has been left out of the pelvic exam for too long.
The clitoral hood is another area to assess. Does it move?
It's a straightforward question, but one that can be overlooked when the exam is focused primarily on the vagina and cervix.
Including the clitoral hood in the exam brings another important part of pelvic anatomy into the clinical conversation.
3. The Muscle Minute
The pelvic floor muscles deserve attention, too.
Just like a knot in your neck, pelvic floor muscles can develop areas of tension that may be relevant to pain.
Assessing pelvic floor muscle tone as part of the pelvic exam adds another piece of information to the overall picture.
The goal isn't to assume that every pelvic pain symptom comes from the muscles. It's to include the muscles in the assessment rather than overlooking them.
Muscle. Tissue. Hormones. It's All Connected.
The Muscle, Tissue & Hormone Screen is a reminder to look beyond the structures we were traditionally taught to examine.
When tissue appears thin, pale, or dry, hormonal factors may be worth considering. The exam is an opportunity to gather information—not to jump to a conclusion.
For providers, this framework offers a way to broaden the pelvic exam with three additional areas of attention.
For patients, it offers language to use when asking about an exam that includes the vestibule, clitoral hood, and pelvic floor muscles.
You should not have to become an anatomy expert to advocate for yourself. And providers should not have to feel that a more complete pelvic exam requires starting from scratch.
You're Already Doing the Exam. Here's What to Look For.
I did not learn to approach the pelvic exam this way in NP school. I learned it one patient at a time.
I know what it feels like to realize there was an entire exam step you were never shown. And I know what it means to meet someone who has been told everything looks normal when their symptoms are still very real.
The gap is not simply about individual providers. It's also about what we were taught—and what our training left out.
That's why I'm bringing the Muscle, Tissue & Hormone Screen to clinicians through trainings, talks, and conversations.
On October 21, from 7:30–8:45 PM ET, I'll be presenting "You're Already Doing the Exam — Here's What to Look For."
If you're a clinician who performs pelvic exams, I hope you'll join me. And if you know a colleague who would benefit from this framework, please share this with them.
