You lie back, legs wide. You relax as much as you can. Anxiety makes you clench, because someone you probably don’t know is about to insert an implement into your vagina. This procedure is what most of us call a smear test (its official name is “cervical screening”) and it is the best prevention we have against cervical cancer, which kills an average of two women a day in the UK. “It’s generally never a pleasant experience,” says Andy Nordin, president of the British Gynaecological Cancer Society. “But it doesn’t have to be an ordeal.”
A cervical screening does not detect cancer itself; it finds cells that are abnormal. An 85% screening rate could see a 27% reduction in deaths over the next five years. But something is going wrong. Cervical screening is at its lowest rate in 19 years. The Jade Goody effect, named for the increase in women attending screening after the reality TV star died of the disease in 2009, has disappeared. In 2015 and 2016, only 72.7% of eligible women went to a screening when invited. That doesn’t sound too bad, but it means 1.2 million women didn’t attend.
What is keeping women away? All sorts: fear of pain; embarrassment; the fact that no woman likes lying supine while being probed with an instrument by a stranger. Perhaps the vaginal speculum has something to answer for. It looks like an alarming tool; its two arms forming the shape of a duck’s bill. There is a screw on the outside that can pinch the labia as it is inserted (although most providers cover it). It can make unsettling noises. In short, it looks like what it is: something devised by male gynaecologists in the 19th century. Nowadays, disposable plastic ones are commonly used. They’re not as cold: speculums being warmed on radiators used to be a common sight. But plastic ones have their flaws, too, and not just the fact that they are disposable and used in their hundreds of thousands. “The plastic speculum can be more difficult to remove,” says Dr Virginia Beckett, of the Royal College of Obstetricians and Gynaecologists. “Plastic doesn’t ‘run’ as well as metal so it can get caught.”
A team at Frog, a San Francisco company that designed early Apple computers, thinks a different design may make the dreaded smear test less dreaded. The idea came when designers Hailey Stewart and Sahana Kumar both had pelvic exams in the same week. “We’re designers,” says Fran Wang, a mechanical engineer who is also on the design team, “and we talk about things that bother us.” Once they got talking, a lot of things bothered them: the lack of information, the cold instrument, the fact that no one ever talked about this stuff. They joined forces with a fourth female colleague and coined a name, Yona, from the Sanskrit word “yoni” for the female life form. They addressed the material. Which industry, they asked themselves, knew about making objects that you insert into your body? They looked at sex toys and chose silicone. Next: the shape. Three arms would be better than two, they decided. They worked on the angles. A speculum’s handle is at 90 degrees, which requires the operator to ask the patient to do what the Yona team call “the last scooch”, an embarrassing shuffle along the table. They changed the angle to 105 degrees to prevent that.
Yona looks less alarming than the metal speculum. But it hasn’t been tested on people with vaginas yet: there is still investment to find, and rigorous clinical trials before that can happen. Still, the Yona team thinks it has done something positive, and not just materially. “We have had so many emails from people,” says Rachel, “telling us the most intimate stuff. We have sparked a conversation.”
Beckett who likes the idea of silicone, though metal has advantages. “Metal conducts heat,” she says, “so it quickly takes on the temperature of the vagina.” Jo’s Cervical Cancer Trust, however, say the current design is adequate. There are all sorts of sizes, for a start, to fit different women. The trust would like to see self-testing, particularly for women who are postmenopausal, with dryer vaginas that make insertion painful, or anyone who has experienced sexual trauma.
Next year, England and Wales will also switch to a different sort of primary screening. Instead of testing first for cells, women will be tested for human papilloma virus (HPV), which causes most cervical cancer. “There is some evidence,” says Nordin, “that to test for HPV you don’t have to get cells from the cervix. That’s where self-testing may come in, if you popped a swab into the lower vagina and tested for the RNA and DNA of the virus. It wouldn’t test for cells, but if you found smear tests painful, it would be better than nothing.”
The smear test isn’t going away, so it has to get better. For Beckett, it’s all about the approach. “If they are given a careful explanation,” she says, “most women tolerate screening very well.” Jo’s Cervical Cancer Trust has tips to deal with anxiety: use a meditation app, wear a skirt or take someone with you. Providers should make sure women know what is happening and that a smear test will probably be uncomfortable, but it shouldn’t be painful. If it is, a woman should feel able to say “stop”.
Indeed, it seems that the key to getting more women to screening and making the screening better isn’t hardware but software. When I had a vaginal examination recently, I was anxious. The nurse was a man (with a chaperone). The gel was cold. I was lying on my back in a vulnerable position. But it was the smoothest procedure I have had for years. Why? Because the nurse did a great Joyce Grenfell impression. Material science is great, but good people-science is better.