‘Have you ever been sexually active?’ The question posed by the healthcare worker in the hospital examination room was to the point, but Sarah didn’t hesitate to answer honestly: ‘No, never.’
That answer changed not only what happened in the 26-year-old’s next few minutes, it changed the entire course of her life.
Sarah was denied a vital check because she is a virgin, which meant it took another eight months before her symptoms were finally diagnosed: she had cancer, and it had spread.
In July 2022, Sarah was in hospital in Manchester having a scan to find out why she was suddenly suffering from such heavy periods and severe pelvic pain that left her bed-bound for a week each month.
She was due to have an internal ultrasound, also known as a transvaginal ultrasound, which is a common procedure offered to hundreds of thousands of women in the UK each year. It involves inserting a small probe into the vagina to give a clear view of the ovaries and womb.
This scan is considered a gold-standard procedure as it can help identify problems such as endometriosis (when cells similar to the lining of the womb develop elsewhere) that may not be visible with an external ultrasound – and even some cancers.
But when Sarah said she had never had sex, the sonographer refused to perform the internal ultrasound.
‘She said that in that case, it would be against her religious beliefs,’ says Sarah, now 29, from Manchester.
‘I said, “Please, it’s not a big deal – can’t you just do it?” But she refused.’
When Sarah said she had never had sex, the sonographer refused to perform the internal ultrasound
The only other option – an external ultrasound – was not possible as it requires a full bladder to work. So Sarah had to go back to her GP for another referral.
Had Sarah had the internal ultrasound as planned, there’s a good chance it would have spotted the early signs of cancer developing in her pelvis. But it wasn’t until eight months later that Sarah – by now not only in pain but hugely bloated – would finally get an internal ultrasound.
‘This time the sonographer asked me the same question as before but said she was happy to do if it I was happy to proceed.’
The experience of the ultrasound itself was ‘fine’, she says, but the findings were anything but.
‘I was told that I not only had endometrial cancer in my womb, but that it had spread to my ovary,’ says Sarah.
‘I was totally stunned, it just hit me like a ton of bricks. My first thought was “oh my god, am I going to die?”’
With a five-and-a-half-inch tumour growing in her right ovary, Sarah had to undergo surgery to remove it. She had no idea whether she would wake up and be told the cancer had spread further, which she said was a ‘horrendous’ experience.
For the tumour on her womb, the removal has been delayed to give her the possibility of having a child, but she’s had a Mirena coil inserted, which releases the hormone progesterone to hopefully control the growth.
Since the surgery on her ovary in February 2023, Sarah has had to have intrusive, painful womb biopsies every three months to check on the progress of her cancer – just one of the many checks she has had to endure that are ‘so much worse than the ultrasound I needed’, she says.
Sarah is now speaking out. She said: ‘I have come across other women who are virgins who have been denied an internal ultrasound. I don’t want anyone else to suffer as I have.’
Internal checks should in principle be available to all women – indeed guidelines from the British Medical Ultrasound Society clearly recommend a patient who ‘has not had penetrative sex’ is entitled to a transvaginal ultrasound and ‘the concept of virginity plays no part in the clinical decision-making’.
Yet these are only guidelines, and hospital trusts are free to make their own.
Irrespective of a trust’s view, as Sarah discovered, the view of the individual sonographer carrying out the health check may also have an effect.
When Sarah complained to the hospital, their response was that the sonographer in question had been provided by a locum agency and they no longer use that particular agency.
They said the trust does offer transvaginal ultrasound to sexually-inactive women, so long as they consent.
Healthcare professionals need to tread with caution if someone is a virgin, says Nitu Bajekal, consultant gynaecologist at Spire Hospital Bushey.
‘These checks may be more painful for them and the pain may put them off healthcare.’
An internal ultrasound could damage the hymen – the delicate membrane that partially stretches across the opening to the vagina.
So too could a smear test, during which a speculum is inserted so that samples can be taken from the cervix (the neck of the womb) to check for signs of cervical cancer.
An intact hymen has traditionally been seen as a sign of virginity, but it can break for many reasons and many women don’t even notice when it happens as often there is no pain.
‘When women have periods, the membrane becomes slightly broken, using tampons will break it – lots of activities will,’ says Cecilia Bottomley, consultant gynaecologist at University College London Hospitals.
Previously gynaecologists were reluctant to undertake internal checks for women if they weren’t sexually active (for fear they would cause pain or break the hymen) – but in recent years this has changed, says Ms Bottomley.
‘We have realised that many women may not have had penetrative sex but they have used tampons or sex toys, for example.
‘But we make no assumptions: we will always undertake discussions to explain why we are offering the check and it is up to the women to decide what is acceptable to her.’
There are other options for those who aren’t willing to have internal vaginal checks.
While an external ultrasound through the abdomen won’t give as clear a view as a transvaginal, a rectal ultrasound, where a lubricated probe is gently inserted into the rectum will, says Ms Bottomley – and may be an option not just for women who have not been sexually active but also to those who, for example, are older and suffer from dry, sensitive skin around the vagina.
MRI is another option, but Ms Bottomley says ‘this is very noisy and can some people find them unpleasant as you lie inside the machine’.
When it comes to cervical screening, there is some confusion among non-sexually active women about whether they need it.
‘We do get a lot of calls from women who wonder if they should be having cervical screening if they have not had penetrative sex – and the answer is yes absolutely,’ says Helen Hyndman, nurse co-ordinator for Ask Eve, an information service run by The Eve Appeal, a gynaecological cancer charity.
‘That’s because although over 99 per cent of cervical cancer cases are linked to the HPV virus, this is spread by skin-to-skin genital contact – not just penetrative sex – rarely, there are also cases not linked to HPV.’
Sarah’s view is women should accept any check they are offered, and herself had a smear test before her cancer diagnosis.
She later found out her GP had wrongly recorded that she had refused the internal ultrasound.
So that meant the next check she got, in November 2022, three months after the sonographer refused to do her internal check, was with an external ultrasound, not an internal one.
The technician doing this noted ‘cysts’ on her ovaries but couldn’t get a clear view – blaming it on Sarah’s growing BMI (a result, it would turn out, of her cancer).
Her GP then referred her to a gynaecologist who, ‘without even seeing me’, put her on a non-urgent pathway.
‘I think having said I was sexually inactive and my age was going against me – no one seemed to think I was at risk of anything serious,’ says Sarah.
By Christmas 2022 she was feeling ‘really unwell, sleeping all the time, my abdomen was large and I had constant heartburn’.
So she went back to her GP, who referred her for another scan – this one the internal which showed the cancers.
The next ‘kick in the teeth’ was that she then needed a hysteroscopy – a far more intrusive internal check, during which the womb is expanded using saline under pressure and a camera inserted to examine it.
‘It was off-the-scale painful,’ says Sarah.
The hysteroscopy revealed that Sarah has endometrial hyperplasia – meaning the lining of the womb is thicker than normal, which heightens the risk of womb cancer – a risk which can be reduced with, for example, a Mirena coil to thin the womb lining.
This was all discovered too late, however.
Rather than start on her placements to achieve her dream of becoming a vet as had been planned, Sarah spent six months in ‘agony’ recovering from the surgery in March 2023 to remove her ovary.
The operation came in the nick of time.
‘They told me the cancer was on the verge of leaking cancer cells elsewhere,’ says Sarah. ‘Had that original scan been done, the cancer might have been seen sooner.’
She has been offered the chance to freeze her eggs, ‘but after all I have been through, I can’t face the idea of more pain,’ she says.
Physically, Sarah says, she feels better, ‘but mentally it’s a struggle as I worry about what’s around the corner and because of what happened I have no confidence in my healthcare team – apart from my oncologist.
‘I have been told I might need a hysterectomy – at the moment they are monitoring me but keep telling me if I want to have children to get on with it – but while I have had partners, none of them has been serious enough to start a family with.’
She still dreams of becoming a vet, but for the meantime has been doing a science degree – studying largely from home – while she gathers her strength.
‘I don’t think women who are sexually inactive should be denied vital checks,’ she says. ‘I don’t accept that this was a rogue sonographer – this is happening to other women and it shouldn’t.’
