The humble speculum is among the most commonly used instruments in obstetrics and gynaecology.

The history of the speculum is as chequered as it is long. The earliest known speculum dates back to 79AD, where a bronze speculum was unearthed from the ashy ruins of Pompeii.¹ There are even earlier reports of speculums made from wood or other organic materials, highlighting that visualisation of the cervix has long been a mainstay in women’s healthcare.²

The modern bivalved or “duck-billed” design in circulation today was largely developed in the 1800s, by Cusco, Graves, and Pederson.³ Their eponymously named respective speculum designs remain the industry standard today, and are the most widely used throughout Australia and New Zealand.

Redevelopments in speculum design have lost momentum since the 19^th century. Though there has been evolution in materials and sterility, the basic design is essentially unchanged from its invention. The likely reason for this is that it works!

Though the speculum is functional and fit for purpose, it is frequently described as uncomfortable by patients.^4,5 This can represent a significant barrier to women seeking timely gynaecological care.⁶

One of the most important consequences is in the cervical cancer screening space. An Australian qualitative study surveying under- and never-screened women identified discomfort during speculum examination as the commonest reason for disengagement in recommended screening.⁷ Since the National Cervical Screening Program expanded the eligibility for self-collected samples in 2022, uptake has been exponential, with self-collect now accounting for 27% of all samples received.⁸ Though this option represents an excellent public health initiative, ultimately there are other times when there is no substitute for clinical examination.

There are a number of frustrations with the current bivalved speculum design. One of the most common complaints is that in women with vaginal wall laxity, such as multiparous women, vaginal wall collapse can impede adequate visualisation of the cervix. Furthermore, the current design opens vertically in the anterior-posterior direction, resulting in wide dilatation of the distal vagina and subsequent discomfort. Sound and temperature can also contribute to the patient experience of speculum examinations, with cold metal or noisy mechanisms reported as potential sources of distress.⁹

Alternative speculum designs have the tall order of overcoming these limitations while also being affordable, sustainable, easily stored, user-friendly, and acceptable to the patient. Easy, right?

Introducing the Alternatives

Bouquet Speculum

The Bouquet speculum represents a complete redesign to the speculum as we know it, featuring five petals that radially open as the speculum advances.¹⁰ This speculum was developed by US physician Dr Jean-Marie Bouquet, whose efforts to innovate the speculum were inspired by his own gripes with current design, and bolstered by a family member’s cervical cancer diagnosis. The multi-petalled design of the Bouquet speculum aims to distribute the force of speculum opening circumferentially rather than vertically and provide a physical barrier to prevent vaginal wall collapse during use.

Clinician surveys conducted overseas indicated that those well-versed in bivalved speculum design face a learning curve when adjusting to this unique design.¹¹ However, a study that compared medical students using the Bouquet speculum and the traditional bivalved speculum in a simulated setting found that time to identify the cervix and introduce an endometrial Pipelle was significantly reduced with use of the Bouquet speculum.¹² The inference that can be made is that, to the uninitiated, it is as user-friendly as our current mainstay.

The Bouquet speculum was approved by the Food and Drug Administration (FDA) in the US in 2015, and international distribution began in 2017. However, this design has limited commercial availability in Australia and New Zealand and is certainly not mainstream at present. The Bouquet speculum is also manufactured as a disposable, plastic device, precluding its reusability and raising sustainability concerns.

Bouquet speculum

Lilium Speculum

Sharing similarities with the Bouquet speculum, the Lilium speculum has three leaves that open radially as an introducer is advanced (similarly to a tampon applicator).¹³ The designers, two engineers based in the Netherlands, were motivated by their personal experiences of discomfort with traditional speculums. It is designed with the option for self-insertion, taking the lead from sonographers who have long offered transvaginal probe self-insertion, citing a possible improvement in patient-perceived autonomy.^14,15

Its current prototype features a semi-flexible rubber base material, making it compatible with autoclave sterilisation, hence conferring the added advantage of reusability. However, at this stage it is just that – a prototype, which has only recently concluded crowdfunding by hopeful consumers. Watch this space!

Lilium speculum. Photographer Patrick Wetzels.

Yona Speculum

At first glance, the Yona speculum looks very similar to its currently available counterparts.¹⁶ However, it can be distinguished from the traditional speculum by its three metal blades and medical-grade silicon exterior. This choice of material endeavours to preserve a comfortable temperature for the patient, whilst ensuring the speculum itself remains suitable for autoclave sterilisation. It has an angled handle designed to avoid impact with the patient’s underlying surface, which is a common problem encountered when examining in non-lithotomy positions. The Yona also features a thumb press button to open and lock the speculum, positioning itself well for one-handed use and noise minimisation.

The Yona speculum is currently an early-stage design concept and is not available for purchase or distribution. Its founders describe it as a work in progress – “today a concept and conversation, tomorrow something much more.”

Yona speculum by Yona Care.

Nella Speculum

In the advent of social media, online platforms abound with algorithmic advertisement. Bring-your-own speculums can now be pitched direct to consumer, the most prominent of which is the Nella speculum.¹⁷ The Nella speculum hails from a designer whose own experiences with infertility inspired her to rethink the current design. The Nella speculum features slimmer blades and a one-handed locking mechanism. It is also marketed to be discretely portable for ease of transport to the gynaecology clinic.

The Nella speculum available for patient purchase is single-use and comes in a variety of kits containing fluffy socks, essential oil rollerballs, and heat pads. So boutique are these packs, they have even been featured in Vogue.¹⁸ The move towards out-of-pocket speculums have been criticised as an effort to privatise women’s health.¹⁹ And though these advertisements have been delivered direct to my Instagram Explore page, they actually aren’t yet available for delivery to Australia or New Zealand addresses.

Nevertheless, the remarkable market success of this product reinforces that modern women are in search of a more comfortable and less intimidating speculum than those traditionally offered. The salient takeaway is that just because something works doesn’t mean it couldn’t work better – the speculum is no exception.

Conclusion

Ultimately, pelvic examination is an inherently vulnerable and intrusive experience for many women. Innovations in design, no matter how revolutionary, will probably never completely address every unpleasant element of speculum examination.

Necessity is the mother of invention, and there is no debate that the current design provides the clinical access required. However, the necessity that is so often overlooked is the fundamental requirement for the equipment we use to be acceptable to women and as comfortable as possible.

Although it is a common attitude to leave well enough alone, we should always be striving for innovation that improves patient experience and empowerment. What better place to start than with one of our most foundational tools – the humble speculum.