Disclaimer: Due to the interwoven and complex nature of gynecological situations and procedures, an orthodox rabbi who is knowledgeable in this area should always be consulted. Note, too, that the following excerpt from the first expanded edition of Family Purity is presently undergoing editing. Thus, the following is supplied as general guidelines.
Gynecological Considerations
Opening of the Uterus. The sages1Niddah 21:a, b. asserted, “There can be no opening of the uterus2Rashi Niddah 21:a. without blood flowing3Mehaber 188:3, Ramo 194:2. This rule applies primarily to the internal os, but also applies to the external os as a stringency, Shiurei Shevet Halevy 188:3, 4..”
This applies not only when something is expelled, such as during menstruation, but also when something is inserted4Shulchan Aruch Admur Hazoken 188:8. This applies for pregnant, nursing, and post-menopausal women, as well, Pischei Teshuva 194:4. Some poskim hold this rule does not apply when something is inserted into the uterus, see Appendix - Gynecology for more deliberations. into the uterus, e.g. a medical instrument.
Some internal gynecological examinations involve penetration into the uterus using various types of medical instruments5For example: an endometrial biopsy with a biopsy curet or a hysteroscopy (visual examination of the uterine cavity through an instrument called a hysteroscope). A number of instruments are used to perform a cervical biopsy, for example: Tischler cervical forceps, Kevorkian-Young forceps, and the Duncan endometrial curet.. When the uterus is penetrated with a medical instrument, the state almost invariably results6See Appendix - Gynecological., even when no sign of blood is present. Therefore, in the event that a medical instrument was inserted into the cervix7See opinions brought in Nishmat Avrahom Volume Two Yoreh Deah on Mehaber 183:2 and 194:2. “Penetration into the cervix causes niddah, or at least requires consultation with an orthodox Rabbi who is knowledgable in these matters,” Shiurei Shevet HaLevy on 188:3. Note Gefen Porioh Chapter One endnote 68. or into the womb8An overview of opinions regarding the width which causes niddah is found in Appendix - Gynecology., an orthodox Rabbi9More sources: Nishmat Avrahom 194:2. knowledgable in these matters must be consulted10In order to accurately consult the Rabbi, the wife should ask the doctor what diameter the instrument was and how far it reached..
In light of the above, it is advisable to arrange such procedures at a time when the woman is already a niddah. If this is not possible, an orthodox Rabbi should be consulted.
Procedures which Cause Niddah
Iud. Insertion or removal of an intrauterine contraceptive device, IUD, renders the niddah state11Gefen Porioh 1:2 and 16:14. Therefore, it is best inserted while the wife is niddah in any case. Note: the hefsek tahara cannot be performed until staining resulting from the placement of the IUD ceases.. An orthodox Rabbi who is knowledgable in these matters should be consulted regarding spotting.
Note: Contraception is permitted only in cases of potential physical or psychological danger to the wife12And through consultation with an orthodox Rabbi knowledgable in these matters and familiar with the circumstances. “When the wife is healthy, birth control is not permissible; in questionably life threatening circumstances it is. When contraception is necessary for other reasons, those and what method is permissible, need to be clarified through a rav who is particularly knowledgeable in this area. It is not possible to write sweeping general guidelines,” Shiurei Shevet Halevy on Mehaber 194:1. “The Torah opposes intentionally limiting family size unless there exists a hazard to life or health.... Such decisions must be deferred to higher competent Rabbinical authority because of the complexity and delicacy of such situations.… They will consider not only instances of acute fatigue which ultimately could contribute to a compromise of physical health or emotional instabilities which may constitute a hazard to mental health,” Gefen Poriah pg. 102..
Other Common Procedures. Bleeding caused by scraping the inside of the cervix; an endometrial biopsy; a hysterogram13Bleeding may be due to irritation from the catheter to the uterus, and thus may be dam makkah (blood of a wound) and not dam niddah.. The couple should consult with an orthodox rabbi for his determination. The patient should be informed of the diameter of the catheter used. 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. or hysterosalpingogram (HSG); a hysteroscopy; a foley bulb (induction for birth) cause niddah.
Staining caused by the Pill, implantation bleeding or premature detachment of the placenta may potentially cause niddah, and a Rabbi who is knowledgeable in this area should be consulted14Generally, these are uterine bleeding which would be judged according.
Procedures which do not Cause Niddah
Regarding this section, it is important to verify that another procedure, or condition, which potentially do cause niddah are not present.
An examination using the fingers15Even when the doctor presses her stomach in order to lower her womb, Tahara Kehalacha Chapter Seven note 22, poskim. only does not render the niddah state16Gefen Porioh. “The wife’s, midwife’s, or the examining doctor’s finger (or the husband’s organ) do not reach the womb to cause the niddah state because of the rule “there can be no opening of the womb without flowing of blood,” Pischei Teshuva 194:4. Igros Moshe Orach Chaim (3) section 100. Responsa of Chosem Sofer 179, see Nishmat Avrahom 192:2. and she is not required to examine herself following such an examination17Gefen Porioh Chapter One note 70..
A transvaginal18Transvaginal means across or through the vagina. Also called an endovaginal ultrasound. ultrasound19A type of pelvic ultrasound used to check the reproductive organs, e.g. uterus, fallopian tubes, ovaries, cervix, and vagina. A transducer is inserted into the vagina only and thus causes no cervical dilation. It is generally well lubricated, thus unlikely to cause bleeding. does not penetrate the cervix and therefore does not cause niddah.
Examining the vagina, even using an instrument20Which is designed to examine the vagina alone and can not reach the uterus., does not render the niddah state21Gefen Porioh 1:18; and Nishmat Avrahom 194:2 citing Beit Yitzchak Yoreh Deah volume 2 section 14, Shut Otzei Levanon section 50, Shut Maharsham volume 4 section 146, and Shut Tzitz Eliezer volume 10 section 25:11.. A standard gynecological examination does not penetrate the womb or cervix22Gefen Porioh Chapter One note 69. “Preferably the physician should be asked if bleeding occurred,” Shiurei Shevet HaLevy on 188:3..
If blood is found following these, an orthodox Rabbi knowledgable in these matters must be consulted23Gefen Porioh 1:18. A physician, or other health care practitioner, reporting the instrument can not reach into the uterus and that it caused a bleeding injury in the vagina is relied upon and the wife does not become niddah, Igros Moshe Orach Chaim volume 4 section 100; Nishmat Avrahom 194:2 cites additional sources..