Patient and public involvement

This study was motivated by the well-documented discomfort and apprehension many patients experience during pelvic examinations, particularly speculum use. The primary objective was to assess patient preference between plastic and metal speculums. Secondary objectives included exploring the reasons behind those preferences, with the aim of informing future interventions to improve patient comfort and reduce barriers to routine gynecologic care.

Study population and recruitment

Participants were recruited from outpatient clinics affiliated with the West Virginia University (WVU) Department of Obstetrics and Gynecology. Eligible patients were invited to participate during routine clinic visits and were provided with a QR code linking directly to the online survey. Upon scanning the code using their personal mobile devices, participants were presented with an electronic consent form. Participation was entirely voluntary and anonymous; completion of the survey served as implied informed consent.

Study design and sampling

This study utilized a convenience sample of consecutive patients presenting to outpatient obstetrics and gynecology clinics during the recruitment period. No a priori power calculation was performed, as the study was designed as an exploratory assessment of patient preferences.

Survey instrument

The survey instrument was developed by the research team based on literature review and clinical expertise. Questions were pilot-tested among a small group of trainees and faculty for clarity and content validity prior to distribution. No previously validated instrument addressing speculum material preference was identified.

Response rate

All eligible patients present during clinic sessions were invited to participate until the pre-decided goal of roughly 200 surveys was obtained. The number of patients who declined participation was not systematically recorded; therefore, an exact response rate cannot be calculated. This may introduce potential selection bias.

Ethical approval and data collection

The study protocol was reviewed and approved by the WVU Institutional Review Board (IRB). Data collection was conducted over an eight-month period, from September 15^th, 2024 through June 16^th, 2025. Survey responses were securely collected and stored using the Qualtrics survey platform. Upon survey completion, participants were given the option to view a summary of aggregate results via the same QR code link.

Data analysis

Descriptive statistics were used to summarize participant demographics and speculum preferences. No identifying individual information was accessed during data collection or analysis. Data was accessed on June 21, 2025 for analysis. Associations between categorical variables were evaluated using chi-square tests. Given the exploratory nature of secondary analyses, no formal correction for multiple comparisons was applied; findings should therefore be interpreted as hypothesis-generating.

Analyses were conducted using complete-case analysis for each variable, excluding missing responses from individual comparisons while retaining overall sample counts. Percentages may not total 100% due to rounding.

Statistical analyses were conducted using Stata 13 (StataCorp LLC, College Station, TX). Additionally, OpenAI’s ChatGPT (GPT-4, 2025) was used as a supplemental tool for automated data processing, visualization development, and exploratory insight generation. The SRQR reporting guideline was used to draft this manuscript, and the SRQR reporting checklist was used when editing.

Study limitations

Several limitations must be acknowledged. Because this study employed a convenience sample without an a priori power calculation, it may have been underpowered to detect small subgroup differences, including age-related associations (disproportionate number of respondents being in the younger age groups). Additionally, the demographic diversity of the sample was limited; the majority of participants identified as cisgender women, making it difficult to draw conclusions about speculum preference across gender identities. As such, the findings may not be generalizable to more diverse or gender-diverse populations. Lastly, the survey did not collect detailed demographic variables such as race, ethnicity, parity, socioeconomic status, or rural versus urban residence. West Virginia has a predominantly non-Hispanic White population (~92%), which may limit generalizability to more diverse populations [15].

Clinical implications and opportunities for improvement

The results highlight the importance of prioritizing patient comfort during pelvic exams. Although plastic speculums were perceived as more comfortable, particularly with regard to insertion and temperature, the speculum itself was not the sole source of discomfort. In this study, only 34% of participants reported the speculum as the most uncomfortable aspect of the exam, while temperature and positioning were also frequently cited (Table 1). These findings suggest that efforts to improve the pelvic exam experience should extend beyond speculum design alone.

One avenue for improvement involves innovation in speculum design. For instance, the Bouquet Speculum, a five-petaled model designed to distribute pressure evenly, has shown promise in improving comfort and visualization [6]. Further studies are warranted to evaluate its impact on patient experience and exam outcomes.

Temperature sensitivity was also a common concern, particularly among those preferring plastic. While warming systems like those used for ultrasound gel may be considered, evidence supporting their effectiveness is limited. One emergency department study found no significant improvement in patient satisfaction when warmed gel was used during point-of-care ultrasound [5]. Further research is needed before recommending widespread adoption of warming systems for speculums.

Positioning is another factor worth revisiting. A clinical trial found that patients reported decreased vulnerability and discomfort when their feet were placed on the edge of the exam table rather than in stirrups, without compromising the quality of Pap smears [3]. This simple modification may be an effective strategy to improve patient experience.

Environmental trade-offs and global perspectives

This study’s findings align with a previous cross-sectional study conducted in five Dutch hospitals, which also found that the majority of patients preferred plastic speculums [14]. However, a key difference was that participants in the Dutch study were more willing to compromise personal comfort for ecological sustainability, while most participants in our study expressed minimal concern about the environmental impact of plastic use as displayed in Table 2 [8,12,13]. However, survey-based studies are more susceptible to social desirability bias, which may influence results. Participants may more likely to report environmental-conscious preference as it is a socially desirable attitude, leading to an overestimation of pro-environmental attitudes [16]. The extend of this bias may vary across populations and cultures contexts, and thus these findings my not fully reflect patient preferences in real-world clinical settings when choosing between metal and plastic speculums [16].

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Table 2. Carbon Footprint Comparison: Plastic vs. Metal Vaginal Speculums [7,8,13].

https://doi.org/10.1371/journal.pone.0346819.t002

Despite the preference for plastic speculums, younger respondents (ages 18–35) were more likely to express environmental concern than older respondents. This discrepancy may indicate that although ecological awareness exists among younger individuals, immediate comfort during an exam could influence preference of speculum more strongly than longer-term environmental considerations. The survey did not directly assess trade-off decision-making between comfort and sustainability; therefore, interpretations regarding prioritization should be considered exploratory. Future research using a discrete choice experiment design would quantify the relative importance of specific attributes of the pelvic exam, such as patient positioning, temperature of speculum, type of speculum, and other contributing factors [17]. Additionally, a randomized crossover study in which patients rate pain, comfort, and overall preference following exposure to both metal and plastic speculums in randomized order would provide prospective, within-subject comparisons and reduce reliance on recall bias present in survey-based designs.

The carbon footprint created from using plastic speculums stems from production, transportation, and waste management of a non-recyclable material [8]. Comparatively, the carbon footprint related to metal speculum use is due to sterilization, either through autoclaving or H2O2 (7.25%), and reduction in emissions from autoclaving can be made by striving to sterilize with full capacity compared to only half full [8]. Reusable metal speculums offer a more sustainable alternative overall after as few as 10 speculum exams [8]. These instruments can be reused up to 500 times, and although the sterilization process contributes to carbon emissions, the overall environmental impact is lower compared to manufacturing single-use plastic devices [7,8,12,13]. However, despite adequate sterile protocols for both metal and plastic speculum handling, metal speculums were perceived as less sanitary in this study, suggesting that patient education on the sterilization process of metal speculums may help increase acceptance of reusable options.

In addition to design modifications, alternative screening approaches such as self-collected vaginal swabs for HPV testing may reduce the need for speculum exams altogether. These have been shown to be as acceptable as clinician-collected samples for primary HPV screening while significantly reducing material use [18]. A study from the UK reported an 8.7-fold reduction in environmental impact using self-sampling [19]. The self-collection method could be particularly beneficial for patients who avoid pelvic exams due to discomfort or trauma histories.