Blog | Tuesday, March 15, 2011

Do women need an annual pelvic exam?

A new article in the Journal of Women's Health by Westhoff, Jones, and Guiahi asks "Do New Guidelines and Technology Make the Routine Pelvic Examination Obsolete?"

The pelvic exam consists of two main components: The insertion of a speculum to visualize the cervix and the bimanual exam where the practitioner inserts two fingers into the vagina and puts the other hand on the abdomen to palpate the uterus and ovaries. The rationales for a pelvic exam in asymptomatic women boil down to these:
--Screening for chlamydia and gonorrhea
--Evaluation before prescribing hormonal contraceptives
--Screening for cervical cancer
--Early detection of ovarian cancer

None of these are supported by the evidence. Eliminating bimanual exams and limiting speculum exams in asymptomatic patients would reduce costs without reducing health benefits, allowing for better use of resources for services of proven benefit. Pelvic exams are necessary only for symptomatic patients and for follow-up of known abnormalities.

Screening for chlamydia and gonorrhea
Screening for chlamydia in young women is evidence-based: It reduces the rate of pelvic inflammatory disease. New tests are available (on urine and self-administered vaginal swabs) that do not require a pelvic exam by a doctor. They are sensitive and cost-effective. Supporting references are listed in the article.

Hormonal contraception
Doctors used to require pelvic exams before they would dispense prescriptions for oral contraceptives. This was never shown to be necessary--no findings from these exams influenced the decision to issue a prescription. One concern, the possibility of a pre-existing pregnancy, can't be entirely ruled out by a pelvic exam, but the risk can be minimized by starting the pills after a normal menstrual period. Now all the major guidelines (from the FDA, WHO, ACOG, Planned Parenthood, etc.) specify that a pelvic exam is not required for hormonal contraception.

Cervical cancer screening
Pap smears have been proven effective in reducing morbidity and mortality from cervical cancer. Speculum exams are necessary to obtain specimens for Pap smears, but Pap smears need not be done annually and speculum exams need not be accompanied by bimanual exams. Current recommendations are to begin screening at age 21 and to re-screen at intervals of two to three years. New technology currently in development may eventually allow for equivalent screening without a pelvic exam.

Ovarian cancer
The evidence shows that bimanual exams are useless for detecting ovarian cancer, and they are no longer recommended for this purpose.

Other benefits and risks of pelvic exams
While other conditions such as fibroids, ovarian cysts, and yeast infections can be detected by examining asymptomatic women, there is no evidence that early diagnosis improves outcomes. Overscreening for cervical cancer has been shown to lead to harm. Findings on pelvic exams can be false positives and can lead to unnecessary interventions.

"U.S. rates of ovarian cystectomy and hysterectomy are more than twice as high as rates in European countries, where the use of the pelvic examination is limited to symptomatic women."

Is it time to abandon the annual pelvic exam?
Yes, I think so. The existing evidence indicates that omitting it in asymptomatic women would not affect health outcomes. This article is representative of a growing consensus in the medical community, especially in other countries; but many U.S. doctors are still doing annual pelvic exams. I suspect (just my opinion) that they are afraid of looking stupid or getting sued if they miss something, or are clinging to what they were taught to do out of inertia. Meanwhile, science-based doctors are leaning away from annual physical exams in general. As WebMD says: The annual physical exam is beloved by many people and their doctors. But studies show that the actual exam isn't very helpful in discovering problems. Leading doctors and medical groups have called the annual physical exam "not necessary" in generally healthy people.

Even in patients being followed for diagnosed diseases, the physical exam sometimes degenerates into a token ritual. I've noticed that although I have no heart or lung symptoms, my own doctors like to check my lungs at every visit by putting the stethoscope on four spots (right, left, front, and back) for one breath each, and to check my heart by applying the stethoscope briefly to one spot. I tolerate it because I know it makes them feel better, but I consider it totally useless.

Admittedly, there is a human element involved: Hands-on interactions and the perception of "doing something" can be reassuring and can enhance the doctor-patient relationship. But can't a caring clinician attain those same benefits within the realm of science-based medicine? A doctor's time is better spent on proven health screening measures and in educating and counseling patients than in carrying out nonproductive rituals.

This post by Harriet Hall, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.