Abstract: Gynecological examinations and procedures that involve dilation of the cervix or cause uterine bleeding can render a woman niddah. There is some debate among halachic authorities on certain parameters that affect the niddah status.
There are generally two issues involved. First, in a case where she bled, can we can be reasonably sure that the bleeding is from the trauma of the exam and not from other uterine bleeding that would render her a niddah? Second, even in a case where she did not bleed, was there halachically significant cervical dilation?
Bleeding following a procedure
When there is bleeding or spotting, there are two important questions: (1) Where did she bleed? And (2) When did she bleed?
Where: Trauma from procedures in the vaginal canal does not make a woman niddah. Thus, a simple manual exam does not change her status to that of niddah. When the bleeding is from a procedure inside the uterus, it is slightly more difficult to assure that the bleeding is only from trauma. Some rabbis are more lenient with this than others. Regarding bleeding from the cervix itself, there is some disagreement among the authorities as to whether it should be judged like the vagina or the uterus. Most authorities maintain that bleeding from the outside of the cervix would certainly be similar to bleeding from the vagina. It is thus important that the physician clearly explain to the woman the most likely source of the bleeding.
When: A woman is halachically presumed not to be niddah from the time she immerses in a mikveh until she expects her next menses. During this time, it is halachically easier to assume that any bleeding is traumatic in origin. On the other hand, during the week prior to mikveh immersion we are trying to assure that she is not bleeding, and the rulings are stricter. For this reason, it is probably best to avoid scheduling gynecological procedures prior to mikveh immersion(unless they involve significant cervical dilatation, which would make her niddah anyway, see below). Similarly it is preferable not to schedule them just prior to the expected period, when we are concerned that the bleeding may signal the beginning of her anticipated menses. Taking such halachic considerations into account when scheduling procedures is of great service to this patient population.
Significant cervical dilation
There is a halachic principle that we assume that any dilation of the cervix beyond a certain point causes uterine bleeding even if no blood is detected. Therefore, even when there is no visible bleeding, a woman may be rendered niddah by a medical procedure if there is significant cervical dilation.
Halachic sources discuss whether this principle should apply only to the natural opening of childbirth or also to interventional opening. The ruling is that, in most cases, it applies to interventional opening as well. For this reason, medical interventions that open the uterus may render a woman niddah, even in the absence of any visible bleeding.
Authorities differ regarding the minimum size of the opening that renders a woman niddah. Possible measurements range from 6mm to 19mm. Thus different women, upon rabbinic consultation, may use different criteria. It is best to discuss the planned size of the instrument with the patient prior to the procedure so she can consult with her rabbi as to his halachic opinion. If he rules that this will make her niddah, she may want to schedule the procedure at a time that she is already niddah. If a smaller instrument is technically possible, this may also be of assistance.
There is further disagreement as to whether this principle refers to the opening of the internal or external os.
Due the above considerations, a rabbinic question will often be asked prior to scheduling any gynecological procedure. The doctor should relate the percentage of bleeding from the procedure, the diameter of the instrument used, and whether there is a specific point during the cycle at which the procedure should be done.
A physician should always note down for his observant patients whether there was any bleeding from the uterus prior to the procedure. If there was bleeding during the procedure, the physician should note what is the most likely source (e.g., abrasion from the instrument), the diameter of any instruments used, expected or possible bleeding and expected duration of this bleeding. This information will help the patient obtain the proper ruling in a timely fashion. A form designed for this purpose is available here.
Implications for Patient Care: Gynecologic examinations and procedures may render a woman niddah.
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. It may be helpful to provide this information on the form available on this site.
Clear explanation of the procedure, instruments used, cause and expected duration of any resulting bleeding should be reiterated after the procedure. It may be helpful to provide this information on the form available on this site.
There may be halachic indications for scheduling a procedure at a particular point in the cycle, as long as not medically contraindicated.