The most hated thing in your doctor’s office just got a much-needed update.

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If you look past the rust, an ancient Roman speculum is instantly recognizable as an instrument a gynecologist might put inside you today. There are two curved metal bills, a screw to hold them apart, and the ghostly echo across the eons of a patient grunting in pain as the doctor employs it.

For centuries, the speculum’s job has been simple and essential: Hold apart the walls of the vagina so a clinician can see inside it, all the way up to the cervix. Most women encounter it every few years for a Pap smear, which screens for cervical cancer, or during an IUD insertion, fertility treatment, or pelvic exam in the case of abnormal bleeding or discharge.

It’s also famously uncomfortable. If the speculum is metal, it’s cold. If it’s plastic, there’s a disconcerting ratcheting sound as it opens, as if the doctor were operating a piece of industrial equipment. There may be pain when the tip is inserted, or when the components expand, ranging from a slight twinge of pressure to searing agony that halts the exam.

Why has one of the most widely used tools in gynecological care barely changed in two millennia?

Medical professionals are under no illusion that the speculum is a comforting device. “It is considered pretty archaic to many patients,” said Monica Rosen, a professor of obstetrics and gynecology at the University of Michigan. Patients with severe anxiety and discomfort are relatively rare, but “at baseline, no one is jumping up and down and saying, ‘Choose me for a speculum exam today!’ ”

Even so, there have been few productive efforts to pioneer a better way. Though specula have been around since ancient times, the modern version has roots in the work of an enslaver and doctor named James Marion Sims, who in 1845 used a double-ended bent spoon to look inside the vaginas of his patients. His first trials with the device were on enslaved women, on whom he operated without anesthesia. In the next few decades, other doctors modified the instrument with a two-bladed duckbill and a screw to hold it open—a design that almost exactly mirrors the specula used today.

Why has one of the most widely used tools in gynecological care barely changed in two millennia? “Because it has to do with women’s health, and women’s health doesn’t get enough money or attention,” said Carrie Sopata, a gynecologist and professor at the University of Virginia. In the past, patient comfort during pelvic exams was an afterthought, if it was thought about at all. The only thing that mattered was the doctor’s ability to do the job.

But over the past decade, Sopata said, “we’ve started to think more about pain and to pay more attention to what patients tell us—and try to believe them.”

In the widespread dissatisfaction with a common device, some have seen an opening for lucrative innovation. The Yona, a prototype that hasn’t made it into production, features metal covered in silicone, which preserves a comfortable temperature and can be sterilized in an autoclave. The Lilium, developed by researchers at a Dutch university who recently concluded a crowdfunding campaign to support further testing, features three leaves that spread open like a flower when a patient deploys a tampon-like applicator. The Nella, the only one of these that is currently available for purchase, boasts a narrower duckbill and a one-handed locking mechanism for clinicians.

The creators of new-edition specula speak of their products not just as gentler alternatives but as critical tools for public health. Cervical cancer is almost entirely preventable with regular screenings every few years, but about 1 in 4 women is not up to date. Studies have shown that people who believe that Pap smears are painful are less likely to schedule regular screenings, contributing to thousands of preventable cervical cancer cases and deaths in the U.S. each year.

Fahti Khosrowshahi, the founder and CEO of the company that produces the Nella, began thinking about creating a new speculum after undergoing three years of fertility treatments and countless speculum exams. As a management consultant for biopharmaceutical companies, she said, “I could see how much money was thrown into different areas of health, and some of them really for mediocre improvements.” She couldn’t believe that such a foundational product in women’s health had evaded the drive for advancement that attended other medical devices and procedures.

Khosrowshahi resigned from her job and, in 2017, turned her attention fully to creating a new speculum. She led a year of research and development, mostly self-funded, with a consumer product design firm and team of OB-GYNs and nurse midwives. Together, they went through dozens of rounds of prototyping, trying to make a functional speculum that would fit most patients and avoid pinching when it closed. The most uncomfortable part for many patients is the insertion, Khosrowshahi said, since the most sensitive nerves are around the vaginal opening, so she was intent on making it as narrow as possible. “I wanted it to be no larger than a regular-sized tampon,” she said. “That was my No. 1 criteria.”

She also hoped to make it quiet. The clicking and clanking of a plastic or metal speculum can cause anxiety that triggers muscle tension, creating even more discomfort and negating the benefits of a narrower device. An unpleasant sound was the death knell for one prototype that Khosrowshahi really hoped would work: a slim catheter with a balloon that expanded inside the vagina. As an instrument that provided a clear view of the cervix, it worked perfectly, but the sound of an inflating balloon was too unnerving to abide.

After testing prototypes on cadavers and sheep, which according to Khosrowshahi possess “a vagina very similar to women,” researchers landed on the design that would become the Nella. They launched a study with human patients, a majority of whom said they preferred the Nella to a standard speculum. The company now makes a few different versions for various life stages and body types, available in reusable or single-use varieties. One of Khosrowshahi’s favorite aspects of the reusable Nella is the polymer from which it’s constructed. “It’s very slick—there’s no lubrication that needs to be used on it. So it just glides inside the body,” she said.

Khosrowshahi wouldn’t share exact sales figures, but she said the number of specula Nella has sold since entering the market in 2022 is “in the millions,” mostly to health care providers. But Nella is also taking cues from the pharma industry, where Khosrowshahi once worked as a consultant, and marketing directly to the patients themselves. In television ads and social media spots, the company has told women to ask their doctors for the Nella or buy one for themselves online. Nella has also partnered with celebrities, including Mindy Kaling and Maria Shriver, to hawk the device at a fraction of their usual ad rates. It’s not immediately clear how strong the pull of fame will be for a medical device most women encounter once every three to five years. Halle Berry, now a menopause influencer and entrepreneur, appeared in a Nella promotional video with Khosrowshahi that currently has 199 likes on Instagram.

The advent of boutique specula paid for out of pocket seems like yet another effort to privatize the health care experience and upsell well-to-do women on a new device to replace the one that, when used for routine cervical cancer screenings, insurers are required by law to fully cover at no cost to the patient.

The $125 Nella specula available for patient purchase are single-use and come with a collection of items—fuzzy socks, a stress ball, a lavender-scented rollerball—that are supposed to imbue the pelvic exam with self-care vibes, though I cannot imagine pulling them out on an exam table. For that matter, it would require a new level of self-advocacy for a patient, and admirable flexibility on the part of a clinician, to accommodate a device brought from home. Though patients have taken on plenty of tasks at home that once happened only under clinical supervision, from nasal-swab COVID tests to telemedicine exams for skin lesions, there is little precedent for providing one’s own medical equipment for a routine exam in a doctor’s office.

Though none of the gynecologists I spoke to had ever had a patient bring their own speculum to an appointment, they all said they’d be open to trying out whatever the patient offered. But Rosen, of the University of Michigan, doesn’t think every provider would be so accommodating of an instrument coming in from outside their practice. “I think there’s an infection risk, and then you are to blame if someone comes down with an infection,” she said. “I don’t even know, to be honest with you, if the university would allow us to use something that someone else brought.” (Nella says its specula are sanitary and individually packaged, same as the ones used in any clinical setting.)

From one angle, the advent of boutique specula paid for out of pocket seems like yet another effort to privatize the health care experience and upsell well-to-do women on a new device to replace the one that, when used for routine cervical cancer screenings, insurers are required by law to fully cover at no cost to the patient. According to the doctors I interviewed, for every pelvic exam patient who experiences severe anxiety stemming from personal trauma or excruciating pain due to a vulvovaginal or skin condition, there are a dozen or more of us who don’t exactly thrill to the experience but don’t find it all that bad. Will we be convinced that we, too, need to optimize our Pap smear experience with a personal “comfort kit” to the tune of $125?

Traditional specula already come in different sizes for different bodies. And for all their supposed innovations, the nouveaux specula can’t get around the fact that there’s only one good way to open the vagina: Stick a couple of things into it, then pull them apart. “All of them exert some outward pressure. All of them have to pass through the opening and into the vaginal canal,” said Julie Chor, a gynecologist and professor of obstetrics and gynecology at UChicago Medicine. “I’m really curious to see how much of a difference it makes in practice.”

Though each contemporary iteration of the speculum boasts features that purportedly make it more pleasant to use than its predecessors, much remains the same. Both the Lilium and the Nella, for instance, have added to the two-bladed duckbilled design a third (and, in Nella’s case, a fourth) blade to better distribute the pressure of expansion in the vagina and keep the side walls from obstructing the clinician’s view. You know what else had three or four expanding blades? Specula from the first century, unearthed at Pompeii.

But there is one new development that could stand to upend the speculum industry. Last year, following in the footsteps of countries like Australia, Denmark, and Sweden, the Food and Drug Administration approved self-collection kits for patients to swab their own vaginas in a doctor’s office to test for HPV, which causes nearly all cases of cervical cancer. Research suggests that this method is equally effective as a Pap smear—in which cervical cells are examined under a microscope for signs of irregularity—at detecting the first signs of what could lead to cancer. And because a clinician never has to use a speculum or see the cervix at all, many patients will find it a much preferable alternative to the traditional method.

Providers have already been doing Pap smears without specula, called blind Paps, using a similar method to the at-home swab: just stick a brush into the vagina and move it around the cervix. It’s standard practice for Rosen in her work at a clinic for patients with disabilities. “They come back just as adequate as if you used a speculum,” she said. “So you don’t necessarily need to put someone through the trauma of a speculum if they wouldn’t be able to handle it.”

A self-swab option, whether in a doctor’s office or at home, could work for anyone with a low risk profile and no history of abnormal Pap smears, Rosen said. Otherwise, “you’d really want to get a good look, a good sample.” With a speculum exam, providers can make sure they’re swabbing all the right places, including any areas that look abnormal.

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Just a few months ago, the FDA went one step further and approved an at-home device to take a sample at home for an HPV test. When a patient purchases a Teal Wand, they first schedule a telemedicine call with a provider who walks them through the screening process. Then, they insert a device that looks like a giant tampon into their vagina, push up and rotate the spongy swab hiding inside the applicator, resheathe the swab, and remove the wand. They mail the swab to a lab and, if they test positive for HPV, receive instructions for potential follow-up testing and care. With in-network insurance, the device is $99; without, it’s $249. Like the Nella, out-of-pocket costs for the Teal Wand can be paid for with a tax-advantaged health savings account.

A spokesperson for the company said that the price is “still offsetting the amount you have to spend to get to and from the doctor, take off work, child care, so it’s still helpful.” She said Teal is currently working to get insurance companies to cover the full cost.

“I think it will play a significant role in cervical cancer screening,” Sopata, of the University of Virginia, said of the advent of swab tests. “It definitely opens the door for people who find pelvic exams uncomfortable, who are fearful of going to see a doctor.” In an ideal world, anyone would be able to access the most convenient, comfortable option for this lifesaving screening. For now, patients will have to pay for the privilege.

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