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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.

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3 Comments:

Anonymous Elizabeth (Aust) said...

It's interesting that the "annual" exam took off in the States before being properly assessed in RC trials.
The UK did a 10 year study and found the exams were unhelpful. Other studies showed the examined group had more unnecessary procedures, surgery, biopsies and some were left with health problems.

The annual exam has never been part of my life. I see the Dr when I have a health issue - asthma when I was younger, now dermatitis and I have my blood pressure and cholesterol checked every 18 mths to 2 years. I don't have cancer screening. I did my own research, looked at my risk profile and considered the actual risks and benefits of the tests. I didn't get that info from a Dr or the Govt.
All cancer screening does harm - it's a Q of weighing up the risks versus the benefits. Every year another test is being sold to us in a one-sided way - at the moment I'm looking at FOT and colonoscopies. I'd never accept the screening authority or a doctor's recommendation to screen....I make up my own mind.

The routine pelvic exam is not recommended here in symptom-free women, I'd refuse it anyway - it's not evidence based and more likely to harm you. Neither is the routine breast or rectal exam - they don't help and breast exams often lead to unnecessary biopsies.

I hate to read US forums on womens' health care - so many women afraid, humiliated, harmed and all for nothing and the way these exams are sold to women is so terribly dishonest and unethical. The use of stirrups says a lot about the way women are viewed as well - they are unnecessary and only used in theatre and during procedures here, not in consult situations.

Also, the widespread use of coercion to force women to have unnecessary gyn and breast exams and voluntary cancer screening - women being refused the Pill, migraine meds, HRT...UNTIL they comply...
I was shocked to read this is life for an American woman. No wonder my American colleagues get their health care out of the country while on business trips and many of your women use on line pharmacies. I don't blame them...to think these women are effectively locked out of health care by doctors forcing their own agenda. I cannot imagine any ethical Dr refusing a woman reliable BC until she agrees to unnecessary and unhelpful gyn and breast exams and until he/she extracts agreement for cancer screening - something that can only ever be an option - because it carries risk to the healthy body. Legally and ethically our informed consent is required for ALL cancer screening. No Dr has the right to make that decision for us or to accept risk on our behalf.
Unplanned pregnancies, abortions, miscarriages and ectopic pregnancies carry FAR more risk to our health and lives. How has this been permitted to go on for so long?

Fortunately, articles like this one will help to raise awareness, but many US women fear their bodies and need medical surveillance and (false) reassurance that all is well..."How do I know I'm healthy, if I haven't been checked?" - that sort of thinking.
It will take time, but hopefully these articles will encourage more women to read further and to question their doctor's advice.

March 23, 2011 at 9:39 AM  
Anonymous Anonymous said...

I had my first pelvic exam given to me without my INFORMED consent. The doctor didn't talk to me at all before doing the procedure. He probably assumed that I'd had one before. I didn't know what was going on and it was very painful and frightening. I'm still trying to cope with the emotional trauma. I don't think I'll ever have a pelvic exam again and I've been trying to find as much info as I can about the CSA blood test that some say is more accurate at detecting cancer than a pap smear. I've been met with a lot of criticism for being repulsed by pelvic exams but I can't help how I feel. I think doctors should be obligated to ask (not just assume) consent. It seems like many people don't care about this issue or avoid talking about it and I'm glad this article had taken up the topic.

August 9, 2011 at 6:21 PM  
Anonymous Anonymous said...

I agree with this. And yet the national OB-GYN professional organization just recommended annual pelvic exams anyway, admitting that the evidence for benefits for mortality reduction, etc. isn't there. Why? Because apparently women still need to be monitored and checked up on by doctors, for blood pressure purposes, weight, discussion of healthy living, etc. But they do BP and cholesterol screening at health fairs and screening days at work, and those of us who are into health and fitness anyway don't need to be babysat by doctors -- especially because we're probably healthier than at least half the docs! So the whole thing seems very paternalistic: you need us to supervise you because we don't think you can be responsible grown-ups who take care of themselves. That said, since pelvic exams aren't decent screening exams for ovarian cancer, and there ARE early symptoms of that deadly cancer, I think the medical community should be doing more to educate women about what symptoms to be alert for, because they're subtle and often only recognized in retrospect. I've NEVER had a doctor tell me that there were actually symptoms of it, and that knowing them could save your life. You have to read stuff on your own to learn that.

August 3, 2012 at 3:41 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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