Wednesday, August 6, 2014
Should you get an annual pelvic exam?
There are many common practices in medicine that are completely useless. For example, it was once common for patients to get a chest X-ray as part of their yearly physical. Someone finally questioned this practice and studied its utility. It turned out that chest X-rays used to screen for cancer failed twice. They often detected non-cancerous abnormalities that led to extensive work-ups, and they failed to catch cancers. The practice has fallen into disuse.
The yearly physical exam has been a medical tradition for many decades. It is another procedure whose utility is questionable. Studies have shown it to increase costs with little benefit. But most internists still recommend them. Are we doing it just for the money?
We try to base our practice on good scientific evidence. Some things are easier to study than others. It’s relatively simple to design a study that looks at whether a pill prevents heart attacks. Figuring out how to evaluate something like the annual physical is more problematic. It’s hard to find endpoints, and many outcomes are vague: how many marriages were saved by impromptu counseling? How many people felt less depressed by being able to talk to their doctor? How many people treated their blood pressure better by getting praise from the doctor?
And as long as you’re in my office, should I stop at just checking your blood pressure and cholesterol? Why not take the time to talk to you and examine you? Yes, I may find things that should have been left alone, but I may be the one who first detects your skin cancer or leaky heart valve.
Deciding what medical procedures are “worth it” isn’t a simple matter, but it is important. This week the American College of Physicians (I am a member) issued a policy statement on pelvic exams. The policy is simple. In otherwise healthy women, don’t do them.
A pelvic exam consists of examining the external genitalia, placing a speculum in the vagina, inspecting the cervix and vagina, usually collecting a Pap smear, then inserting 2 fingers while feeling the belly with the other hand. This allows the doctor to feel the ovaries and tubes, uterus and bladder.
There is no magic to the pelvic exam. Since the vagina is part of the body, it gets examined. Skipping the genitals seems about as smart as skipping the lung exam. What is so special about the genitals that we should skip them?
In the ACPs new recommendations they looked at existing studies to try to assess the benefit of the pelvic in preventing disease and death. Not surprisingly, they did not find much benefit, but when doing a “study of other studies” this sort of thing isn’t easy to measure.
They also looked at the potential harm of the pelvic exam. The “harms” they looked at were those due to the exam itself, and the extra tests that an exam can lead to:
“The evaluated harms included fear, anxiety, embarrassment, pain, and discomfort.
Most studies included only women in their reproductive years. The overall quality of the studies was low.
Harms of pelvic examination include unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain, and discomfort.”
I find the “emotional” component idiotic in this sense: it assumes that women are too psychologically fragile to have their genitals examined, and it assumes that gynecologists have no training or common sense in dealing with survivors of abuse, assault, and rape. This is an argument for better doctoring, not for abandoning an exam altogether.
The harms seem a bit overblown, and weren’t quantified all that well. How many pelvic exams does it take to diagnose one patient with ovarian cancer? How many does it take for a patient to disclose to her doctor a history of unsafe sexual practices, difficulties with intercourse, or a history of rape?
It’s important to note that the guidelines to not address Pap smears or exams on women with symptoms associated with the pelvis.
I find the recommendations put out by internists to be paternalistic and premature. The data aren’t sufficient to draw conclusions. It seems arbitrary to leave out a particular body part from a physical exam. If good studies are done in the future, ones designed specifically to evaluate the best way to approach women’s health, we should use that data to change our practices. For now, I see no good reason to eliminate the female genitals from the physical exam.
Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
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.
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Suneel Dhand, MD, ACP Member
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