Many women feel uncomfortable during gynecological exams. Multiply those feelings for women who have great difficulty just getting up on the table.
Many women gripe about mammograms. But consider those who cannot even stand up to reach the machinery.
Women with hand and arm difficulties may not be able to give themselves breast exams and women with sight or hearing impairments also need assistance.
As a result, women with disabilities are less likely to receive the tests that can discover cancer and other health problems.
But they do have hope that health care professionals will get new equipment--and more cooperative attitudes on the part of physicians and technicians.
"We can't reach out to these women if we don't have somewhere dignified and respectful where they can go. They don't like being hauled onto a table by three people," says Shirley MacKenzie, coordinator of breast consultation services at Breast Access for Women with Disabilities at Alta Bates Medical Center in Berkeley, Calif.
"Women with severe disabilities have reported that physicians are unable to give them complete pelvic exams and mammograms," said a recent report by the Center for Research on Women With Disabilities at Baylor College of Medicine in Houston, Tex.
One of the biggest problems cited by the study is the examination table.
Women in wheelchairs are seated 16 inches lower than the examining table. Disabled women, therefore, often require assistance from several persons to mount the tables.
An estimated 28 million women with disabilities are not in institutions and may need assistance with specialized medical care, according to Sandra Welner, a gynecologist in Silver Spring, Md., who has written extensively on disabilities, trained other doctors and developed a special table for pelvic exams.
Welner has designed a table that lowers to wheelchair height so that women don't have to pivot or struggle up steps. The table also has handrails so that women can pull themselves up and down.
The table is also equipped with soft, padded boots to hold the legs. The boots can be positioned gently as needed and then comfortably secured in the stirrups.
This is particularly helpful if the patient is spastic or has other problems that make it difficult to position the legs. Women who are tense, uncomfortable or spastic can be placed in alternative positions. Gentle leg stretching or the application of a numbing gel also can help reduce spasms and discomfort.
The tables cost about $6,000 each and have been on the market since 1996, but they are still rare. Welner spends much of her time training other doctors to be more sensitive and showing them how to meet the special needs of the disabled.
The Baylor study reports that severely disabled women receive incomplete or inconclusive examinations and the more severe her disability the less likely a woman is to receive a mammogram.
"Among women with disabilities who had not had a mammogram in the past two years, the most frequently given reason was inability to get in the required position," according to the Baylor study.
One mammogram machine is designed for women in wheelchairs. Called the Bennett contour machine, it tilts forward so that the wheelchair can move in closer, says Kathy Sullivan of Trex Medical Corp. Bennett Division in Copiague, N.Y.
Palms of Pasadena Hospital in St. Petersburg, Fla., uses the machine with good results. "Women feel more secure if they can stay in their wheelchairs," says Dale Rogers, director of radiology.
The advantage is the additional angle that provides a closer image of the chest and easier access for women in wheelchairs. "Most important is the ability to get images close to the chest walls where breast cancer can be missed," says Rogers.
For those health care centers without the special equipment, additional training can still improve the process for disabled women.
For example, technicians at Morton Plant Mease Health Care in Pinellas County, Fla., see many patients with disabilities and have had classes on how to handle them.
If the sides come off the wheelchair, an exam and mammogram can be done from the chair, says Valerie Holley, manager of mammography. Alternatively, patients can be placed on stools or on chairs with high backs.
"It's a matter of working with the patient. You have to become their best friend in about 10 minutes," says Holley.
"Most all machines can get in really close. It's more a matter of technical expertise, taking time and making the woman understand what's going to happen," Holley said.
Health experts agree that a baseline mammogram should be done at age 40 and then every other year until 50, when women should get annual tests. In addition, many public health campaigns promote the importance of women over 40 examining their own breasts for possible lumps.
Yet, some disabled women can not easily examine themselves.
Women with limited arm motion or hand dexterity, such as those with cerebral palsy, multiple sclerosis and quadriplegia, may be unable to perform self-exams. Also, they may not be comfortable being examined by caregivers or family members, says Welner, the gynecologist in Silver Spring, leaving them more dependent on health care professionals to find possible problems.
And women with vision impairments face their own sets of barriers to routine health care.
In fact, the National Institutes of Health is now sponsoring a research project on a new breast self-examination training program for visually impaired women, conducted by MammaCare in Gainesville, Fla.