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Abstract: Gynecological procedures may make a woman niddah. In some cases, there may be halachic indications for scheduling a procedure at a particular point in the cycle, as long as not medically contraindicated. A clear explanation of the planned procedure, any instruments used, and expected duration of any resulting bleeding should be given to the patient prior to performance of a procedure whenever possible. Specific procedures are discussed below:
Bimanual Exam
As the bimanual exam takes place entirely within the vaginal canal [1], there is no issue of cervical dilation that could render a woman niddah (see Principles of Gynecological Procedures). If there is no bleeding, the woman is not niddah. Small amounts of blood on the gloved fingers can usually be attributed to abrasion of the walls of the vagina, especially if the woman is in a condition where her vaginal lining is friable. Thus, in most cases, a bimanual exam would not render a woman a niddah.
Cervical Biopsy
Both the grasping with a tenaculum and the biopsy can cause bleeding [2]. However, this bleeding is definitely traumatic and not hormonal. Therefore, this examination does not make a woman niddah.
Colposcopy
The considerations for colposcopy are the same as those for the speculum exam [3]. The examination would generally not render a women niddah. If a brown-colored substance such as iodine wash (povidine) is used, the woman should be warned to expect a brownish discharge that is most likely from the wash.
Endometrial Biopsy
Uterine bleeding will almost definitely result from this procedure [4]. Therefore, the couple should first consult with their rabbi to determine whether this bleeding, which is caused by trauma, will render the woman niddah. The patient should be told the diameter of the catheter used so she can convey the information to the rabbi.
Hysterogram or Hysterosalpingogram (HSG)
Bleeding after this procedure may be due to irritation from the catheter to the uterus [5], and thus may be dam makkah (blood of a wound) and not dam niddah (hormonal blood that would render her a niddah). The couple should consult with a rabbi for his determination. The patient should be informed of the diameter of the catheter used.
It should be noted that for the HSG a colored dye is used and the cervix is cleaned with betadine, which is brown. Therefore, colors other than blood may appear.
Hysteroscopy
When performing a hysteroscopy, the physician is able to see whether trauma is resulting from the scope [6]. The size of the scope, whether it caused bleeding, and the exact location of the bleeding, should be conveyed to the rabbi to determine if the woman is niddah. The cervix is often grasped with a tenaculum, which commonly causes bleeding from the outside of the cervix. The rabbi should be informed if a tenaculum was used.
Papanicolaou (Pap) smear
Use of the spatula, cotton tipped applicator, or brush for this test does not cause sufficient cervical dilation to render a woman niddah [7], even according to the most stringent opinion. The bleeding that sometimes accompanies this procedure is due to confirmed trauma to the outside of the cervix. Therefore, this exam should not render her a niddah according to almost all authorities.
Speculum Exam
As the speculum examination does not enter the cervix at all [8] , it does not present a problem of niddah due to cervical dilation. One should note if there was any bleeding from the cervix on inspection. If blood is seen exiting the cervix, the woman becomes a niddah. If there is no bleeding from the cervix, she is not a niddah. A small amount of blood on the blades of the speculum can be attributed to abrasion of the walls of the vagina. This is especially true if the woman is in a condition where her vaginal lining is friable and in cases where lubrication was not used.
Vaginal Ultrasound
The transducer is inserted into the vagina only and thus causes no cervical dilation [9]. It is generally well lubricated and thus unlikely to cause bleeding. Performance of this exam should not render a woman a niddah.
Implications for Patient Care: There are differences of halachic opinion as to which examinations and procedures render a woman niddah. Therefore, unless the need for the procedure is urgent, it is best to give a woman all the relevant information prior to their performance to allow her time to consult with her rabbi. Specifically, she needs to know
- if she is likely to bleed from the procedure and if so, the probable source of the bleeding
- if the procedure must be scheduled for medical reasons at a particular time of the menstrual cycle
- the diameter of any instrument used and if it will enter the cervical canal and/or the uterus.
Forms for reporting relevant information to the patient and/or her rabbi both before and after a procedure are available on this site.
If an examination or procedure will make a woman niddah, she may prefer to have it close to a time she is niddah anyway. If it will not render her niddah, then the timing is less important. In all cases, it is best not to schedule procedures during the seven clean days, when even minor spotting from abrasions could invalidate her halachic self examinations. If the procedure cannot be scheduled for a different part of the cycle, she be instructed to consult a rabbi as to how best to proceed with her self examinations.
Medical References
[1] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:148-49.
[2] DeCherney AH, Nathan L, eds. Current Obstetrics & Gynecologic Diagnosis & Treatment 9th ed. Norwalk: McGraw-Hill/Appleton & Lange, 2003:584-85.
[3] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:872-75.
[4] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:232-33.
[5] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:233-36.
[6] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:236-39.
[7] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:147, 869-70.
[8] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:147, 144-46.
[9] Stenchever MA, Droegemueller W, eds. Comprehensive Gynecology. 4th ed. St. Louis: Mosby, 2001:220.
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