Under any circumstances, a pelvic exam is uncomfortable.

The invasive practice requires a doctor to insert a speculum into a patient’s vagina to examine her cervix and to insert fingers into that patient’s vagina while pressing her abdomen to feel her reproductive organs. Even when it’s medically necessary, it is unpleasant. But when it’s not — when it’s instead performed only because of a state mandate — doctors say the examination can be traumatizing.

In Missouri, this issue — the subject of back-to-back episodes of Rachel Maddow’s MSNBC show — is at the center of the fight over the fate of the state’s last abortion clinic.

A St. Louis Planned Parenthood facility sued the state last week to prevent it from allowing the clinic’s license to expire, claiming the health department was unfairly targeting the clinic because of the governor’s staunch antiabortion views. The state agency, meanwhile, has claimed that the clinic violated laws and regulations, including a requirement that doctors give patients a pelvic exam at least 72 hours before an abortion, even if the patient is receiving a nonsurgical medication abortion.

The pelvic exam requirements are designed to make it as difficult as possible for women to receive abortions, said David Eisenberg, the clinic’s medical director.

“It is even more uncomfortable and awkward for women when they understand the reason it is being done is because the state is requiring it,” Eisenberg said in an interview Friday. “They are being victimized by a state regulatory process that has gone awry. It is not making them healthier, it is not making them safer, it is only victimizing them.”

Planned Parenthood has argued, in court and in interviews, that the state has recently shifted its interpretation of the code. Before Randall Williams took over as director of the Missouri Department of Health and Senior Services two years ago, Eisenberg said, agency officials agreed with the clinic’s decision to perform pelvic exams only before surgical abortions — not before a medication abortion, also known as the abortion pill.

But in a 2018 inspection, the agency cited the clinic for not performing the exam before medication abortions, the first time it happened in Eisenberg’s decade of working there, he said.

At the time, Williams said in an interview with the St. Louis Post-Dispatch that pelvic exams are a part of standard care for women receiving gynecological services. “We think that our job is to ensure the safety of women undergoing these procedures,” he said.

But Eisenberg and his fellow physicians felt that the requirement in the case of medication abortions was unethical. They decided to stop administering medication abortions and instead send patients across the border to a clinic in Illinois, where regulations are not as strict.

A year later, during the facility’s 2019 inspection, the health department again issued a citation. This time, the agency said the clinic needed to perform a pelvic exam at least three days before a surgical abortion, during “informed consent,” a state-required counseling session. (Also during this time, a doctor must tell a woman, “The life of each human being begins at conception. Abortion will terminate the life of a separate, unique, living human being.”)

Until then, Planned Parenthood had performed the exam on the day of the abortion, “at the time it is most relevant and appropriate,” the clinic’s lawsuit said. But to comply with the state, Eisenberg said, the clinic’s doctors now do the checkup twice, once days before the procedure and again on the day of it.

“The field we are playing on all of a sudden has different dimensions, and the rules we are playing by have been changed by the referees,” Eisenberg said.

The health department did not respond to requests for comment about the pelvic exam requirements or the agency’s interpretation of them.

The American College of Obstetricians and Gynecologists recommends that “the decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician-gynecologist or other gynecologic care provider.”

Missouri Right to Life, a group opposed to abortion rights, has applauded Williams and his department’s stringent enforcement.

“No one and no healthcare facility is above the law,” Susan Klein, the group’s executive director, said in a statement.

Medical professionals have said the state is putting patients in greater danger, especially those who became pregnant after a sexual assault and for whom a pelvic exam could be especially disturbing.

“I have had to accompany patients to a pelvic exam bc of what it triggers,” Jessica Gold, a psychiatry professor at Washington University medical school in St. Louis, said in a tweet. “Imagine having to be that triggered, for a medically unnecessary reason. ... Trauma multiplies.”

Eisenberg said that for someone “who has been the victim of sexual assault, that exam can be miserably painful — physically, emotionally and psychologically.”

But, he said, it’s probably the clinic’s new normal.

Maddow likened the practice to “state-sanctioned sexual assault.”

“State-sanctioned sexual assault is the new price that the state of Missouri is extracting from Missouri women if they try to get an abortion,” she said Thursday, “Now, why would the state government do that? What is the benefit to the state of doing that?”

Both sides of the abortion rights debate in Missouri have been waiting on Circuit Judge Michael Stelzer to issue a ruling. He heard arguments this week, but it is unclear when he will decide whether the clinic can continue performing abortions.